Upper Extremity Injury: Clinical Correlations

Question 1

types of fractures

Answer 1

acute
stress
pathologic

Question 2

acute fracture mechanisms

Answer 2

from sudden impact of large force exceeding strength of bone

Question 3

stress fracture mechanism

Answer 3

from repetitive sub maximal stresses

Question 4

pathologic fracture mechanism

Answer 4

from normal forces to diseased bone

Question 5

what to look for on a fracture exam?

Answer 5

deformity
bleeding +/- fragment=suspect open fracture=orthopadeic emergency=needs to be surgically washed out asap!
bony point tenderness
pain with loading bone (indirect loading especially useful)

Question 6

indirect loading tests

Answer 6

axial loading
bump test
fulcrum test
hop test

Question 7

fracture diagnostics-what imaging can be used?

Answer 7

plain x-rays
CT scans
bone scan
MRI

Question 8

fracture treatments

Answer 8

immobilization (in general)

avoidance of NSAIDs (some animal studies and models show NSAIDs interfere with bony healing via PGs)

Question 9

what diagnosis are you most concerned with when addressing a FOOSH injury?

Answer 9

scaphoid fracture

Question 10

bones with “vulnerable” blood supplies-retrograde areas and watershed regions

Answer 10

retrograde areas: scaphoid, talus, and femoral head

watershed region: central (tarsal) navicular

Question 11

snuffbox contents

Answer 11

radial nerve
cephalic vein
radial artery
scaphoid bone (deepest part)

Question 12

what vasculature innervation do you worry about becoming compromised with a femoral head fracture?

Answer 12

medial circumflex femoral artery=most important blood supply to the head and neck of the femur
–the artery of ligament of the femoral head only gets a small amount of innervation from this

Question 13

what would you find in the history and exam in a patient with arthritis?

Answer 13

history:
     stiffness-especially after rest
     worse after prolonged use
exam:
     joint line tenderness
     mild swelling
     deformity
     symptoms with both passive and active motions

Question 14

Adhesive capsulitis-findings and causes/risks

Answer 14

capsular thickening
-see inflammation and scarring
idiopathic or post injury
-risk factors: injury, diabetes, thyroid disease

Question 15

Adhesive capsulitis history

Answer 15

limited range-of-motion (ROM)

• painful early stage with decreasing ROM (freeze phase)
• non-painful with stable, decreased ROM (frozen phase)
• non-painful with improving ROM (thawing phase)

Question 16

what would you see on a adhesive capsulitis exam?

Answer 16

decreased ROM
gradual tightening endpoint
exam otherwise consistent with underlying etiology

Question 17

Adhesive capsulitis treatment

Answer 17

reassurance
educate and set expectations
maintenance of ROM
pain control

Question 18

key components to treatments of musculotendinous ruptrues

Answer 18

impact of absence of muscle
presence of alternative muscles
functional requirements of patient

Question 19

enthesopathy

Answer 19

disorder of muscular or tendinous bony attachment

Question 20

tendinitis

Answer 20

technically acute inflammation of tendon

traumatic=blow or pull

Question 21

tendinosis

Answer 21

chronic degenerative condition of tendon

chronic=submaximal repetitive irritation

Question 22

strain

Answer 22

muscle fiber damage from over stretching

-eccentric loading (muscle lengthening during firing)

Question 23

strain symptoms

Answer 23

stiffness
bruising
swelling
soreness

Question 24

acromioclavicular (AC) sprain etiology, presentation, and exam findings

Answer 24

etiology-most commonly fall directly onto shoulder
presentation-pain with overhead motions, deformity of superior shoulder
exam:
-pain and deformity at the AC joint
-pain with cross body adduction of arm (positive cross-chest test)
-painful arc of abduction over 150 degrees

Question 25

AC injury grading

Answer 25

grade I=AC ligament injury
grade II=AC ligament tear and coracoclavicular (CC) ligament stretch
grade III=complete tears of both AC and CC ligaments
grade IV=complete tears of both AC and CC ligaments and clavicular displacement

Question 26

sprain

Answer 26

ligamentous damage from overloading

Question 27

symptoms of sprain

Answer 27

instability or laxity

swelling

Question 28

sprain grading (pathology and exam findings)

Answer 28

grade I=microscopic damage; on exam: no increased laxity, but pain with stress
gade II=partial tear; on exam: increased laxity and pain
grade III=complete tear; on exam: significant laxity

Question 29

which nerve innervation can become compromised in a patient with an anterior shoulder dislocation? How do you test whether or not this nerve is working?

Answer 29

axillary and radial nerves
to test the axillary nerve, test deltoid abduction motion–supraspinatus is responsible for the first 30 degrees of abduction, deltoid is responsible for abduction of the shoulder past 30 degrees

Question 30

joint stability…difference between dislocation, sub laxation and laxity

Answer 30

dislocation=complete displacement
sublaxation=transient, partial displacement
laxity=normal variant in “joint looseness”

Question 31

shoulder dislocation…epidemiology and etiology

Answer 31

epidemiology=anterior shoulder dislocations-90%
etiology=forced extension, abduction, and external rotation of the arm (eg. open arm tackle or fall onto abducted arm); direct blow to posterior shoulder

Question 32

findings in a patient with a dislocated shoulder

Answer 32

-arm held by opposite hand in slight abduction and external rotation
-alteration of shoulder contour including:
prominent acromion
humeral head anterior to acromion and adjacent to coracoid
-check sensation of axillary and musculocutaneous nerves
-positive apprehension test-feeling of instability with stress

Question 33

carpal tunnel syndrome

Answer 33

parathesias in the velar side of the radial 3.5 digits, thenar wasting (late finding)