Upper Extremity Injury: Clinical Correlations

Question 1

What are the three mechanisms of fracture?

Answer 1

Acute: from sudden impact of large force exceeding strength of the bone Stress: from repetitive submaximal stresses Pathologic: from normal forces to diseased bone

Question 2

What do you look for on examination of a fracture?

Answer 2

Deformity: if bleeding with/without fragment suspect open fracture – orthopedic emergency, needs to be surgically washed out Bony point tenderness Pain with loading bone: indirect loading especially useful

Question 3

What are some examples of indirect loading tests?

Answer 3

Axial loading

Bump test

Fulcrum test

Hop test

Question 4

What imaging modalities may be used to diagnose a fracture?

Answer 4

Plain x-rays

CT scan

Bone scan

MRI

Question 5

What should be done for fracture treatments?

Answer 5

Immobilization

Avoidance of NSAIDS: some animal studies and models show NSAIDS interfere with bone healing via PGs

Question 6

What bones are vulnerable to lack of blood supply with break?

Answer 6

Scaphoid

Talus

Femoral head

Question 7

What are the contents of the anatomical snuffbox?

Answer 7

• Nerve: radial
• Vein: cepalic
• Artery: radial
• Bone: scaphoid

Question 8

What is the artery that supplies a large amount of blood to the head of the femur?

Answer 8

Medial circumflex femoral artery = most important blood supply to the head and neck of the femur

Question 9

What does the history and exam look like for arthritis?

Answer 9

• History: Stiffness – especially after rest, worse after prolonged use
• Exam: joint line tenderness, mild swelling, deformity, symptoms with both passive and active motions

Question 10

What is arthritis?

Answer 10

Damage to articular cartilage surface

Can be acute or chronic

Question 11

What is capsulitis?

Answer 11

Capsular thickening – from inflammation or scarrin g

Idiopathic or post injury – risk factors: injury, diabetes, thyroid disease

Question 12

How does someone with capsulitis usually present their history?

Answer 12

Limited ROM

• Painful early with decreased ROM (freeze phase)
• Non-painful with stable, decreased ROM (frozen phase)
• Non-painful with improving ROM (thawing phase)

Question 13

What will the exam look like for someone with capsulitis?

Answer 13

• Decreased ROM
• Gradually tightening endpoint
• Exam otherwise consistent with underlying etiology

Question 14

What is used for the treatment of capsulitis?

Answer 14

• Reassurance
• Educate and set expectations
• Maintenance of ROM
• Pain control

Question 15

What is a good treatment for a rupture of the long head of the biceps?

Answer 15

Clinical observation (nothing) – usually does quite well on its own

Question 16

What are some key components to consider when treating musculotendinous ruptures?

Answer 16

• Impact of absence of muscle
• Presence of alternative muscles
• Functional requirements of patient

Question 17

What is enthesopathy?

Answer 17

A disorder of muscular or tendinous bony attachment

Question 18

What is tendonitis?

Answer 18

Technically acute inflammation of the tendon

Traumatic – blow or pull

Question 19

What is tendinosis?

Answer 19

Chronic degenerative condition of tendon

Chronic – submaximal repetitive irritation

Question 20

How do most AC (acromioclavicular) sprains occur?

Answer 20

Most commonly from a fall directly onto shoulder

Question 21

What does presentation and exam of AC sprain look like?

Answer 21

Presentation: pain with overhead motions, deformity of superior shoulder

Exam: pain and deformity of AC joint, pain with cross body adduction of arm (positive cross-chest test), painful arc of abduction over 150 degrees

Question 22

Explain the grading of AC injuries.

Answer 22

Grade 1: AC ligament injury

Grade 2: AC ligament tear and coracoclavicular (CC) liagment stretch

Grade 3: complete tears of both AC and CC ligaments

Question 23

What is a sprain? What are some symptoms?

Answer 23

Ligamentous damage from overloading

Symptoms: Instability or laxity, swelling

Question 24

Explain the grading of sprains.

Answer 24

Grade 1: microscopic damage, no increased laxity, but pain with stress

Grade 2: partial tear, increased laxity and pain

Grade 3: complete tear, significant laxity

Question 25

Which way is the shoulder most likely to dislocate?

Answer 25

Anteriorly – usually due to forced extension, abduction and external rotatin of arm or a direct blow to posterior shoulder

Question 26

Which nerve is most likely to get hurt with anterior shoulder disloation? How would you test this?

Answer 26

Axillary nerve

Test with ability to abduct the arm because the deltoid is innervated by the axillary nerve

Question 27

What are the various terms used to describe joint stability?

Answer 27

• Dislocation: complete displacement
• Subluxation: transient, partial displacement
• Laxity: normal varient in “joint looseness”

Question 28

What is the most effective passive stabilizer of the shoulder?

Answer 28

Vacuum phenomena: negative pressure associated with keeping humoral head in place

Question 29

What does the exam for shoulder dislocation look like?

Answer 29

• Arm held by opposite hand in slight abduction and external rotation
• Alteration of shoulder contouring: prominent acromion, humeral head anterior to acromion and adjacent to coracoid
• Check sensation of axillary (deltoid area) and musculocutaneous (forearm) nerves
• Positive apprehension test

Question 30

What causes carpal tunnel syndrome?

Answer 30

Impingement of palmar cutaneous branch of median nerve

Question 31

What clincal findings are consistent with carpal tunnel?

Answer 31

Patient awakens at night with tingling, pain, or both in sensory distribution of median nerve (volar side of radial 3.5 digits)

Thenar atrophy with PROLONGED carpal tunnel

Question 32

Do you need surgery with a rotator cuff tear?

Answer 32

Not necessarily. There are a lot of other muscles that can still do the work.