Upper Extremity Orthopedic Conditions Flashcards
shoulder pain possible causes
Impingement
- Subacromial bursitis
- Rotator cuff tendonitis
- Biceps tendonitis
Rotator Cuff Tear
-Partial or full thickness tear
Arthritis of Glenohumeral Joint or Acromioclavicular Joint
clinical symptoms of shoulder pain
- Pain with attempts at overhead or “impingement” type motion
- Pain that prevents them from sleeping on affected side
- Radiating pain into bicep and down into forearm
- Associated upper back and neck pain
- Loss of strength
- Loss of shoulder range of motion
shoulder pain physical exam
- Inspect for any visible deformity
- Palpate for any point tenderness over biciptal groove, AC joint, posterior subacromial area
- Passive and active ROM
- Strength testing
- Special tests: Jobe (empty can), Neer, Hawkins, Speeds, Cross-body Adduction, Drop Arm
shoulder pain diagnostics
- Xray shoulder: AP, lateral and axillary view to r/o arthritic changes, evaluate shape of acromion, previous trauma
- MRI if suspect tear of rotator cuff (non contrast)
- Use contrast for instability work up
shoulder pain treatment if pain is suspected from impingement
- Oral NSAID course (4-6 wks), activity modification, physical therapy to strengthen rotator cuff and scapular musculature
- Cortisone injection: subacromial, posterolateral approach: Diagnostic as well
- No benefit from injection after 3-4 weeks then consider MRI to r/o tear of rotator cuff
- Can give cortisone injections every 3-4 months
shoulder pain treatment if pain is suspected from biceps tendonitis
- Oral NSAID course (4-6 wks), activity modification, physical therapy to strengthen rotator cuff and scapular musculature
- Cortisone injection: do not inject directly into tendon!
shoulder pain treatment if pain suspected due to rotator cuff injury
- MRI to confirm diagnosis
- Consider cortisone injection (subacromial) for pain control
- Full thickness tear, surgical referral if pt wants surgery
- Partial tear, suggest conservative treatment (see impingement)
shoulder pain treatment if pain suspected due to AC joint or GH joint arthritis
- Depending on severity may end up going straight to cortisone injection of affected area
- If extremely severe and failed conservative treatment, surgical consult
glenohumeral dislocation anterior
o Anterior dislocation most common
o Occur from either external rotation or abduction force on the humerus, a direct posterior force to the proximal humerus or posterolateral blow to the shoulder
o Anterior capsule becomes stretched or torn
glenohumeral dislocation posterior
o Posterior less common
o Posterior capsule torn or stretched
o Caused by posterior force when arm is adducted and internally rotated
o “party trick” where patient is able to sublux shoulder in and out: Subscapularis can be injured at insertion
glenohumeral dislocation clinical symptoms and physical exam
Clinical Symptoms
- Painful for patient, often associated w trauma
- Will likely be gaurding and holding arm at their side
Physical Exam
- Difficult due to pain
- Careful assessment of axillary nerve (document clearly!)
glenohumeral dislocation diagnostics and treatment
Diagnostics
- Xray of shoulder to rule out fracture of glenoid or humeral head
- Post reduction films necessary!
Treatment
-Needs to be reduced! Leave that to ER lecture
hill sachs lesion
o Hill Sachs lesion: a compression fracture of the posterolateral articular surface of the humeral head.
o Created by the sharp edge of anterior glenoid as the humeral head dislocates over it.
o Reverse Hill Sachs lesion: anterior articular surface of humerus
why do we care about dislocations
o Buzz words associated with dislocations, instability and shoulder surgery
o When large both the Hill Sachs and Bankhart lesions may predispose patient to recurrent instability with external rotation and abduction of shoulder
after shoulder dislocations are reduced
Orthopedic management: anterior
- Anterior dislocation: conservative management
- Short period of immobilization
- Gradual advance to passive rom, then active rom, then advance to strengthening
- Can be a long 3-5 month process
- If continued instability 6 months plus after injury than refer to surgeon
Orthopedic management: posterior
-Not as common, I always review these with surgeon on first visit and defer to their treatment plan
Increased chance to repeat dislocation
AC joint injury
o Typically caused by direct downward blow to the tip of the shoulder
o Severity of injury dependent on structures that are compromised
-Grade I
-Grade II
-Grade III
-Grade IV-VI
AC joint injury grades
Grade I
- Partial tear of acromioclavicular joint ligament
- No superior separation of clavicle from acromion
Grade II
- Full tear of acromioclavicular joint ligament, coracoclavicular ligament may be partially torn
- Subluxation or partial separation of clavicle from acromion
Grade III
- Both acromioclavicular joint and coracoclavicular ligaments are torn
- Complete separation of the clavicle from the acromion
Grade IV-VI
AC joint injury clinical symptoms and physical exam
Clinical Symptoms
- Focal pain and swelling over AC joint
- Pain with attempt at overhead motion of arm or cross-body adduction
Physical Exam
- Inspect for deformity over AC joint
- Focalized tenderness over AC joint
- With mild injuries can access AC joint with cross body abduction (may be too painful for grade II or higher)
AC joint injury diagnostics and treatment
Diagnostics
- Xrays: AP, lateral and axillary
- AP of both shoulders helpful if displacement or widening of joint not obvious
Treatment
- Non operative (grade I-III)
- Brief period of immobilization, followed by passive range of motion of shoulder and gradually progress to active range of motion with focus on strengthening surrounding structures
thoracic outlet syndrome
o Compression of brachial plexus and/or subclavian vessels as they exit the space between the superior shoulder girdle and the first rib
o More commonly affects females between ages 20-50
o Cause may be secondary to congenital abnormalities
thoracic outlet syndrome clinical symptoms and physical exam
Clinical symptoms
- Symptoms often vague
- May mimic distal nerve entrapment
- Symptoms from vascular compression cause intermittent swelling or discoloring of skin
- Fatigue and/or aching may be worse with arm overhead
Physical exam
o Inspect for swelling or discoloration of skin
o Compare distal pulses
o Thorough nerve function test
o Elevated Arm Stress Test (EAST): with shoulders abducted at 90 deg and braced somewhat posteriorly have patient open and close fists at moderate speed for 3 minutes. Reproduction of neurologic and/or vascular symptoms is a positive test. Fatigue wo neuro or vascular symptoms is inconclusive or negative.
thoracic outlet syndrome diagnostics and treatment
Diagnostics
- Xray of shoulder
- Nerve conduction study, Electromyography
- MRI
Treatment
- Muscle strengthening and postural education
- Activity modification: limit prolonged overhead activity, avoid heavy straps over affected upper extremity, etc
olecranon bursitis
o Bursa lies superficial on extensor side of the elbow
o May be secondary to trauma, inflammation or infection
o Gout, rheumatoid arthritis, chondrocalicnosis can cause inflammation of bursa
olecranon bursitis clinical symptoms and physical exam
Clinical Symptoms
- Patients note limited ROM of elbow due to swelling and discomfort
- Not always point tender
- Make sure to ask about fever, chills, nausea, vomiting
Physical Exam
- Visible large mass over tip of elbow
- Redness or erythema to skin not uncommon
olecranon bursitis treatment
- If mass is small: compression, NSAIDs, ice and limited use of elbow
- If mass is large: aspiration
- Cloudy fluid or suspect infection: send aspirate for cell count, cultures, gram stain and crystals
lateral epicondylitis
o Also known as “tennis elbow”
o Occurs at site of origin of the extensor carpi radialis brevis
o Due to tissue degeneration with fibroblast and microvascular hyperplasia
medial epicondylitis
o Also known as “golfers or bowlers elbow”
o Occurs in common tendinous origin of flexor/pronator muscles just distal to medial epicondyle
o Less common than lateral epicondylitis
epicondylitis clinical symptoms
- Report gradual onset of pain
- Pain can extend into forearm musculature to the wrist
- Lateral: pain with wrist extension and/or forearm supination
- Medial: pain with wrist flexion and/or forearm pronation
epicondylitis physical exam and diagnostics
Physical Exam
- Point tender over or just distal to origination of affected musculature
- Pain with resisted wrist and/or forearm action
Diagnostics
-Xray to rule out any bony abnormality
epicondylitis treatment
- NSAIDs
- Ice, massage, topical creams
- Activity modification
- Bracing: elbow strap and or wrist brace
- Cortisone injection: locate point of maximal tenderness for target spot to inject
- Surgery: debridement and possible release of tendon
Cubital tunnel syndrome
o Compression of the ulnar nerve at the cubital tunnel along the medial aspect of the elbow
o Second most common compression neuropathy in upper extremity
o Exacerbated by prolonged flexion of elbow
cubital tunnel syndrome clinical symptoms and physical exam
Clinical Symptoms
- Parasthesia and numbness of ring and small fingers
- Nighttime pain
Physical Exam
- Inspect for atrophy of muscles innervated by ulnar nerve
- Palpate nerve to see if it is mobile within the tunnel
- Tinel sign, Elbow flexion test
cubital tunnel syndrome diagnosis and treatment
Diagnosis
-Nerve Conduction Study
Treatment
- Elbow pad to protect nerve
- Splint for nighttime comfort w elbow in 45 deg flexion
- NSAIDs
- Surgical treatment: decompression (release) or ulnar nerve transposition
Release: the ligament “roof” of the cubital tunnel is cut and divided. This increases the size of the tunnel and decreases pressure on the nerve
Transposition: the nerve is moved from its place behind the medial epicondyle to a new place in front of it. This is called an anterior transposition of the ulnar nerve. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition).
carpal tunnel syndrome
o Compression of the median nerve within the carpal tunnel
o Most common compression neuropathy in upper extremity
o Commonly affects middle aged or pregnant women
o Often idiopathic but is associated with pregnancy, flexor tenosynovitis, overuse, inflammatory conditions, trauma to the wrist, endocrine disorders and tumors
carpal tunnel clinical symptoms
- Numbness in thumb, index and middle fingers
- Pain awakens them at nighttime
- Aching pain radiates up arm or into thenar area
- Inability to open jars or clumsiness with holding objects
- Pain with driving or keyboarding
carpal tunnel physical exam and diagnostics
Physical Exam
- Inspect for thenar atrophy
- Phalen maneuver and Tinel sign
- Durkan carpal compression test
Diagnostics
-Nerve conduction study
carpal tunnel syndrome treatment
- Bracing (esp nighttime, driving)
- NSAIDs
- Ergonomic modifictions
- Cortisone injection
- Surgical release: open or endoscopic
ganglion cysts
o Arises from the capsule of a joint or a tendon synovial sheath
o Cyst contains thick, clear, mucinous fluid
o Most common soft tissue tumors of the hand and wrist
o Can develop and disappear spontaneously
o Common locations dorsum of wrist, volar radial aspect of wrist and base of the finger
ganglion cysts clinical symptoms and physical exam
Clinical Symptoms
- Visible mass or lump that may fluctuate in size
- May be painful with range of motion at the affected joint or point tender to pressure
Physical Exam
- Soft, mobile mass
- May be multilobulated
ganglion cysts diagnostic testing and treatment
Diagnostics
-Xray to rule out bony abnormality
Treatment
- If it is not painful than I tell patients to leave it alone
- If it is causing pain or discomfort can attempt aspiration of cyst (mindful of volar wrist area)
- Surgical excision also an option if aspiration unsuccessful
De Quervain tenosynovitis
o Swelling of sheath that surrounds abductor pollicus longus and extensor pollicis brevis at radial styloid area
o Causes constriction of tendon as it moves through the sheath
o Symptoms provoked when thumb abducted and flexed and/or when hand is ulnarly deviated
De quervain tenosynovitis clinical symptoms and physical exam
Clinical Symptoms
- Pain, swelling and tenderness over radial styloid
- Pain with thumb flexion, abduction w wrist ulnarly deviated
Physical Exam
- Finkelstein test: provocative test to produce symptoms. Flex thumb into palm and ulnar deviate the wrist
- Usually positive with De Quervains diagnosis
De quervain tenosynovities diagnostics and treatment
Diagnostics
-Xray helpful to ensure no bony abnormality (wrist series)
Treatment
- NSAIDs, immobilization, physical therapy, activity modification
- Cortisone injection
- Surgery
trigger finger
o Inflammation of flexor tendon or first annular pulley
o Affects smooth flexion of finger causing hitching, snapping, triggering or locking
o Middle, ring fingers and thumb most commonly affected
o Idiopathic or associated with rheumatoid arthritis or diabetes mellitus
trigger finger clinical symptoms, physical exam, and diagnostics
Clinical Symptoms
- Pain, catching or locking when attempt finger flexion
- Painful nodule in the distal palm
Physical Exam
- Painful palpable nodule at distal palmar crease
- Palpable hitching along flexor tendon as passively flex finger
Diagnostics
-Not needed, clinical diagnosis
trigger finger treatment and injection technique
Treatment
- Cortisone injection into flexor sheath
- Surgical release of A1 pulley if symptoms refractory to injection
Injection technique
- Idea is to bathe tissue with anti inflammatory liquid
- Use 1ml syringe with small needle
- Do not inject fluid directly into tendon
Dupuytren disease
- Nodular thickening on palmar surface of hand
- More common between 40-60, men
- More common in little, ring fingers and thumb (web space)
- Cause flexion contractures at mcp joint
- Predisposing factors: northern European ancestry, alcoholism, diabetes, smoking
- family history can = more aggressive disease
dupuytren disease clinical symptoms and diagnostics
Clinical Symptoms
- Patients may have painful nodules near distal palmar crease
- Progress to flexion contractures usually non painful
Diagnostics
-Not needed, clinical diagnosis!
dupuytren disease treatment
- Surgical
- Considered when 30 deg flexion contracture or greater at the mcp joint
- OR
- Flexion at the pip joint
thumb carpometacarpal joint arthritis clinical symptoms and physical exam
Clinical Symptoms
- Pain with grip and pinching
- Difficulty opening jars or door handles due to pain
- Aching nighttime pain
Physical Exam
- Inspect for deformity at CMC joint
- Grind test
thumb carpometacarpal joint arthritis diagnostics and treatment
Diagnostics
-Xray: AP, lateral and oblique of thumb
Treatment
- NSAIDs
- Bracing
- Heat, topical cream
- Cortisone injection
- Surgical joint reconstruction
fracture care and follow up
o Initially fractures will be quite swollen and a splint is used for immobilization. If injury initially seen in urgent or primary care setting than patient is typically referred to an Orthopedic provider.
o Stable fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment
o Unstable fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention
o ALWAYS note neurovascular status when documenting!
fracture care and follow up: stable vs unstable fractures
- Diagnosed stable fracture can be immobilized in variety of ways: cast or splint most common
- Diagnosed unstable fractures are typically immobilized in NWB cast or if post surgical NWB splint (remember swelling issue)
Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing
-If healing progress is shown than cast/immobilizer may be removed and a less restrictive modality may be considered as well as initiating WB if not already doing so.
Unstable fractures return to clinic often 1 week apart to check alignment of fracture by doing an X-ray in cast
-At 4-6 week mark depending on fracture, cast may be removed and new one placed. WB status may be considered, but if still questionable conservative treatment is typically to continue NWB modality.
fracture care and follow up
o In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together). True evidence of bone healing not usually seen on Xray until approx 4 weeks out from DOI. By 8-10 weeks out from DOI smaller fractures are considered healed and may slowly begin normal activity as tolerated. If fracture has been reduced or in area of poor blood supply may take 12-14 weeks out from DOI.
o This is stuff you learn as you go, it always depends on who you are working with, where the fracture is and the type of fracture. But these are general guidelines that have helped me through my first few months alone in clinic.
o Always keep “when can I start range of motion?” in mind.
