Upper Limb Flashcards
A 52 year old male presents with gradual-onset, anterolateral shoulder pain, worse on overhead movements. It is worse at night. On examination he has a painful arc. He is investigated with an MR arthrogram. What is the diagnosis and most appropriate management?
Rotator cuff related shoulder pain.
Relative rest and active rehab
What is the Hawkin’s test used to diagnose?
Impingement
What is the Neer’s test used to diagnose?
Impingement
What is the Jobe’s test used to diagnose
Impingement
What are the stages of rotator cuff syndrome?
I: oedema and haemorrhage, <25, reversiblele with conservative management
II: Fibrosis and tendinitis, 25-40, recurrent pain with activity
III: Bone spurs and tendon rupture, >40, progressive disability, Needs cuff repair
A 47 year old man presents with gradual onset lateral deltoid pain and shoulder weakness, it is worse with overhead activity. He has a positive painful arc and weakness in ER but negative drop arm test. What is the most likely diagnosis and management?
Partial thickness rotator cuff tear.
Relative rest, analgesia and active rehab.
Surgery if chronic
A 47 year old man presents with acute onset lateral deltoid pain and shoulder weakness, it is worse with overhead activity. He has a positive painful arc and weakness in ER with positive drop arm test. What is the most likely diagnosis and management?
Full thickness rotator cuff tear.
Early surgical repair
A rugby player receives a blow to an abducted ER, extended arm and presents after acute pain and restricted ROM. He has loss of the normal shoulder contour. What is the management?
Early reduction using Spazo technique. Check neuromuscular status, Polysling then x-ray.
Refer to T&O within 1 week
What pathologies can occur alongside shoulder dislocation?
Banklart lesion: soft - labrum (90% of <30s), bony: bone avulsion
Hill-Sachs: Cortical depression in humeral head created from compression of glenoid rim
What are the risk factors suggesting possible fracture after a dislocation?
- Age >40
- 1st time dislocation
- Significantly traumatic mechanism
Which patients need early surgery after shoulder dislocation?
- Irreducible dislocations
- Displaced greater tuberosity fractures
- Bankart fractures with instability
What is TUBS instability?
Traumatic, Unidirectional with Bankart lesion, needing Surgery
- Mostly anterior shoulder dislocations
Which surgery has faster return to sport after shoulder dislocation?
Lararjet procedure
8 weeks: full ROM, RTS 12 weeks
(Vs 3-4 months for Bankart repair)
What is the cardinal sign of posterior shoulder dislocation?
Limited ER
What is the classic presentation for someone with AIOS?
Recurrent pain when throwing, recurrent subluxations, ‘dead arm’ syndrome.
What is AIOS instability?
Acquired Instability Overuse Syndrome
What examination findings would there be for an individual with AIOS?
Positive apprehension and relocation test
Scapular dyskinesia, GIRD, labral pathology
What is AMBRI instability?
Acquired Multidirectional Bilateral instability, that often responds to Rehab but may require Inferior Capsular shift
What is the typical presentation of someone with AMBRI?
Hypermobile, or repetitive trauma, especially at extremes of motion
What are the examination findings of someone with AMBRI?
Positive Posterior subluxation test
Weak ER
What is the management of someone with AMBRI?
Avoid stretching, rehab
May require inferior capsular shift
What is the Polar classification of shoulder instability?
Type I: Traumatic/structural
Type II: Atraumatic/structural
Type III: Muscle patterning/non-structural
An individual falls onto an outstretched elbow and reports anterior shoulder pain. They have clicking and pain in the cocking position. What is the likely underlying diagnosis?
Labral tear
What is the O’Brien’s test used to diagnose?
SLAP lesions
What is the Crank test used to diagnose?
Labral tear
What is the Speeds test used to diagnose?
Bicep and SLAP lesion
What is the gold-standard test for a Labral tear?
Arthroscopy
What is the management for a Labral tear?
Active rehab - also used for scapula dyskinesia and GIRD
Surgery if persistent
An 20 year old individual presents with shoulder stiffness. On examination they have reduced cross-body adduction and IR. What is the likely diagnosis and management?
GIRD (Glenohumeral Internal Rotation Deficit)
Stretching, strengthening and taping
What stretches are used for GIRD?
Cross-body stretch and sleeper stretch
What are the different type and movement patterns of scapula dyskinesis?
Type I: Prominent inferior angle, reduced posterior tilt
Type II: Prominent medial border, reduced ER
Type III: Prominent superior border, reduced upward rotation
What is the most common mechanism of injury for a clavicle fracture?
Fall onto point of the shoulder/ direct contact
A 23 year old horse rider presented with pain in her shoulder after falling off her horse. There is localised tenderness and swelling to the superior shoulder. What are the top differentials?
ACJ fracture
ACJ dislocation
What is the management for a clavicle fracture?
Figure of 8 bandage to prevent foreshortening, monitor for 3-4 weeks.
Self assisted shoulder flexion to 90 degrees
What are the indications for surgery after a clavicle fracture?
Skin compromised by bony fragments, foreshortening >1-2cm, non-union
Type IIa and IIb fractures (medial to CC ligament or between CC ligament)
A 24 year old rugby player presents a few days after a match with shoulder pain. He reports he had a dodgy tackle and landed on his shoulder during the match. Since then it has been painful when lying on that side in bed. What examination findings would you expect for ACJ disruption?
Tender directly over ACJ
Step deformity
Positive scarf test
Pain on horizontal flexion
What scoring system is used for ACJ injuries
Rockwood score
What is the management for ACJ disruption according to the Rockwood score?
I: PRICE + ROM exercises ASAP, RTS as per pain (~2 weeks), overhead 6 weeks
II: Same as I but few days in sling
III: Sling 2-3 weeks. ROM + strength ASAP. Normal activity in 6-12 weeks. RTS when full ROM and strength regained
IV-VI: Surgery
A 45 year old weight lifter presents after a sudden sharp pain in his arm and a tearing sensation when lifting weights. His pain has now resolved. On testing elbow flexion there is a visible lump in his upper arm. What is the likely diagnosis and management?
Long head of biceps rupture
MRI/USS
Surgery if performing powersports otherwise can reassure
A 38 year old weight lifter presents after sudden pain in his medial arm during a bench press. He has localised swelling and tenderness. Resisted adduction is weak. What is the likely diagnosis and management?
Pectoralis Major tear
Partial rupture: use + strengthening programme
Complete: Surgery
A cricket fielder presents with significant sudden onset posterior shoulder pain after an impressive catch in a match where his arm was abducted. On examination he has increased passive ER and weakness of IR. Gerber lift off sign is positive. What is the most likely diagnosis and management?
Subscapularis tear
Immediate surgical repair
A 45 year old woman presents with deep throbbing shoulder pain which is worse at night. She gets a sharp sudden pain when she dropped her keys and tried to catch them. On examination she is tender over the coracoid and apprehension test is positive. Passive ER is very painful. What is the likely diagnosis?
Frozen shoulder
What is the usual time course for frozen shoulder?
18-24 months
A 24 year old rugby player is in severe pain after a shoulder-to-shoulder contact in a game. There is local pain and swelling to the sternal border on the injured side. What are the different grades of SCJ injury?
1st degree: most common, sprain
2nd degree: Clavicle subluxes - complete tear of SCL, partial tear of CCL
3rd degree: Complete tear of SCL and CCL, complete dislocation
What is the management for SCJ subluxation?
Figure of 8 bandage 1-2 weeks + symptomatic management
What is the management for an SCJ anterior dislocation?
Reduce with lateral traction on abducted arm and pressure on medial clavicle. Immobilise 3-4 weeks
What is the management for a SCJ Posterior dislocation?
Closed reduction under GA as soon as possible. Figure-of-8 bandage for 4 weeks
A 24 year old weightlifter presented with exertional antecubital pain. Examination reveals pain on resisted flexion and supination. Hook test is normal. Tilt test is positive. What is the position for MRI and the likely diagnosis?
FABS MRI
Biceps overload
A 22 year old boxer presents with intermittent pain in their arm with a progressive loss of flexion. During their last fight they had a momentary loss of arm function as their arm went dead. On examination there is pain on end of range flexion. What is the likely diagnosis?
Anterior impingement
A 25 year old diabetic weight lifter presents with pain on full elbow extension which is affecting their training. They have pain and comparable weakness on resisted elbow extension. What is the likely diagnosis?
Triceps overload
What is the Veigas test used to diagnose?
Triceps rupture
A 24 year old rugby player falls onto an outstretched hand and develops sudden pain, bruising of the posterior elbow and an inability to extend their arm against gravity. What is the likely diagnosis?
Triceps tendon rupture
A 24 year old boxer has reported gradually worsening pain particularly after a missed punch. He has now lost range in his fights due to an inability to fully extend his arm. He reports intermittent locking of his arm and there is pain at end of range extension on examination. What is the likely diagnosis?
Posterior impingement
What are the different types of presentation for lateral elbow tendinopathy?
- Insidious onset 24-72 hours after unaccustomed repeat wrist extension
- Sudden onset lateral elbow pain after single wrist extensor exertion
What tendon is typically affected in lateral epicondylitis when there is pain on resisted wrist extension?
ECRB
What tendons are typically affected in lateral epicondylitis when there is pain on resisted middle finger extension?
ECU/ED
An individual presents with lateral elbow pain after a recent fall, landing on the elbow with no fracture detected in X-ray. They have maximal tenderness over the anterolateral aspect of the radial head. Diagnosis is confirmed on USS. What is the likely diagnosis?
Radiohumeral bursitis
What is the Mill’s test used to diagnose?
Lateral epicondylitis
What is Maudley’s test used to diagnose?
Lateral epicondylitis
What is Cozen’s test used to diagnose?
Lateral epicondylitis
A 45 year old tennis player who uses a lot of topspin presents with gradually worsening medial elbow pain. On examination they have pain on wrist flexion and pronation. What is the likely diagnosis?
Medial epicondylitis
A 24 year old pitcher presents after acute pain in this elbow during a game. He was throwing a pitch and felt a pop in his elbow. He was unable to continue. On examination he has tenderness just distal to the medial epicondyle with pain on valgus stress. What is the likely diagnosis?
Medial collateral ligament sprain
What is the typical presentation of a chronic medial collateral ligament sprain?
Gradual onset pain localised to the medial elbow, worse on late cocking or early acceleration phase
What does the milking manoeuvre test?
Medial/Ulnar Collateral Ligament
What amount of displacement indicates an elbow fracture is stable?
<2mm
What is the most common complication of elbow fractures?
Stiffness
What age group most commonly get supracondylar elbow fractures, and by what mechanism?
Children ~12 years old
FOOSA (e.g. from height/bicycle)
What is the management for a supracondylar elbow fracture?
They are rotationally unstable so an orthopedic emergency.
Required closed reduction under GA
What indicates an olecranon fracture is stable?
If they can extend their arm against gravity and it is non-displaced
What is the management for a stable olecranon fracture?
Immobilise for 2-3 weeks in a posterior splint. Then use a removable splint + ROM programme
What is the management for an unstable olecranon fracture?
Open reduction and internal fixation
What are the associated injuries with a radial head fracture?
Capitellum, coronoid and olecranon fractures
MCL ligament injury
What is the grading for radial head fractures?
I: Undisplaced
II: Displaced wedge fragment
III: Comminuted
IV: Fracture dislocation
What is the management for type I radial head fractures and healing time?
Splint + early ROM, complete healing in 6-8 weeks
What injury pattern is the terrible triad?
Coronoid fracture (usually avulsion)
Radial head fracture
Elbow dislocation
What is the typical mechanism of injury for a posterior elbow dislocation?
FOOSH - shoulder abducted, axial compression, forearm supinated then forced flexion of the elbow
What is the grading for posterior elbow dislocations?
- Subluxation
- Incomplete dislocation (perched)
- Complete dislocation
What is the management for a posterior elbow dislocation with an undisplaced radial fracture?
Conservative management: sling for 2-3 weeks
Also for small coronoid fractures
What is the management for posterior elbow dislocations associated with large coronoid fracture?
Reduced and fixed surgically
What is the management for a posterior elbow subluxation?
Brace/splint with forearm in pronation
What is the main ligament preventing posterolateral and rotator instability?
Ulnar part of LCL
A rugby player with a previous elbow dislocation presents with recurrent painful clicking and reports their arm intermittently locks in extension. Positive chair test. What is the likely diagnosis?
Posterolateral and rotatory instability (PLRI)
What test is used to test for posterolateral rotatory instability?
Posterolateral rotatory apprehension test
Chair test
Push up test
What is the management for chronic posterolateral and rotatory instability?
Ligament reconstruction with a free ligament autograft
A pitcher is attempting to throw his PB speed when he feels sudden pain and instability in his medial elbow. How do you assess laxity and what ligament is affected?
Test valgus stress at 30 degrees
Acute rupture of MCL
What is the management of an incomplete acute MCL rupture?
Protect in a brace. Muscle strengthening for 3-6 weeks. Gradual return to sport
What is the management for an acute complete elbow MCL rupture, and why?
Surgical repair as prone to instability
A cheerleader feels sudden onset pain in the elbow during training after trying to catch a team member when they fell out of a lift. The team mate landed on their forearm causing them both to fall and which forced their elbow into hyperextension. They were unable to continue training. What is the likely ligament injury?
Stress to the anterior band of the MCLC
What is a Monteggia fracture?
Ulnar fracture with radial head dislocation at the elbow
What is a Galeazzi fracture?
Radial fracture with dislocated ulnar at wrist
What is the acceptable amount of angulation in a radius and ulnar fracture in a child? What is the management over this amount?
Up to 10 degrees. Otherwise reduce under LA or GA. Immobilise in pronation
What is the amount of acceptable angulation in a radial and ulnar fracture in an adult for return to sport?
Needs perfect reduction. Most will need internal fixation then cast/crepe bandage for 8-10 weeks
What is the management of stress fractures?
Rest, correct any predisposing factors
What is the typical presentation of Posterior Interosseous Nerve entrapment?
Maximum tenderness over the supinator muscle. Pain over forearm extensor mass
Pain on resisted supination, with elbow flexed to 90 degrees
Aching wrist
Pain in mid/upper 1/3 humeral pain
What is the management for PIN entrapment?
Soft tissue therapy over supinator at entrapment site
Neural tissue mobilisation
A competitive arm wrestler complains of generalised anterior elbow pain which radiates into their forearm. They have paraesthesia over the first three fingers. They have subtle wasting of the thenar muscles and it is starting to affect them competing. What is the likely diagnosis and management?
Pronation Teres Syndrome (Median Nerve Entrapment)
Activity modification. Occasionally required surgical resection of the humeral head of pronation teres
What are the indications for an open reduction of a distal radius fracture?
Dorsal communition
Intraarticular involvement
Instability on reduction
Dorsal angulation >20 degrees
Articular surface step >1mm
Radial shortening >5mm
What is the management of a distal radius fracture if there is volar plate involvement?
Surgical intervention with early mobilisation
What is the conservative management of a distal radius fracture?
Reduction with cast in <20 degrees flexion and ulnar deviation (x-ray at 3 and 6 weeks)
What are the 3 examination findings that suggest scaphoid fracture?
- Tender over anatomic snuffbox
- Tender over scaphoid tuberosity (in radial deviation)
- Pain on axial compression of the thumb
What is the management for a stable scaphoid fracture?
Immobilise for 8 weeks in scaphoid cast
What scaphoid fractures require immediate percutaneous reduction and internal fixation?
Unstable, angulated >15-20 degrees or significantly displaced fractures
What is the management of a scaphoid fracture with incomplete union after 8 weeks in a scaphoid cast?
Immobilise for further 4-6 weeks
What is the management of a scaphoid fracture with non-union?
CT. Fixation with simple bone graft
What is the management of necrosis after a scaphoid fracture?
Vascularised bone graft
What is the typical mechanism of injury and the complications of a trapezium fracture?
MOI: Axial compression from thumb metacarpal
Complications: Often accompanied by a Bennett’s fracture, degenerative arthritis, reduced carpometacarpal motion, painful pinch grip
What is the management of a non-displaced trapezium fracture?
Thumb spica cast
A 14 year old gymnast presents with dorsal wrist pain associated with training. XR shows haziness around the physis. What is the likely diagnosis?
Radial epiphyseal injury
What is a complication of a radial epiphyseal injury?
Positive ulnar variance
What is the management of a radial epiphyseal injury?
Rest
Adaptive technique
Flexor strengthening + bracing (to reduce hyperextension)
Alternate swinging and loading skills in training
What is the pathophysiology of De Quervain’s Tenosynovitis?
Affects the synovium of APL and EPB tendons in fibrosseous tunnel at radial styloid
What is the Finklestein test used to diagnose?
De Quervain’s tenosynovitis and FCR tendinopathy
What is the management of De Quervain’s tenosynovitis?
Splinting, local eletrotherapeutic modalities, stretches and graduated strengthening
Pen build-up and golf-grip widener reduces stretch on tendons
CSI + LA can help
In rare cases surgical release is necessary
A 22 year old elite rower presents with wrist pain and a crunching sensation when they move their wrist. On examination it is swollen on the radial side of the wrist with tenderness proximal to the radial styloid. What is the most likely diagnosis and appropriate management?
Intersection syndrome
Acute surgical intervention with immediate return to training and events
In non rowers CSI into the junction
What is the pathophysiology of intersection syndrome?
True tendonitis between the 1st (APL + ERB) and 2nd (ECRB + ECRL) dorsal wrist tendon compartments
What is contained in extensor compartment 1 of the wrist?
Abductor pollicis longus + Extensor pollicis brevis
What is contained in extensor compartment 2 of the wrist?
Extensor carpi radialis longus + Extensor carpi radialis brevis
What is contained in extensor compartment 3 of the wrist?
Extensor pollicis longus
What is contained in extensor compartment 4 of the wrist?
Extensor digitorum + Extensor indices
What is contained in extensor compartment 5 of the wrist?
Extensor digiti minimi
What is contained in extensor compartment 6 of the wrist?
Extensor carpi ulnaris
What are the possible treatment options for a painful ganglion?
Aspiration +/- CSI infiltration under USS: has a temporary effect
Persistent ganglions: Surgery - remove neck
What x-ray view is best to diagnose, and what are the x-ray findings for an anterior dislocation of lunate?
Lateral view
Lunate tilted volarly, not articulating with capitate
What is the management of an anterior dislocation of lunate?
Urgent open reduction and primary ligament repair followed by cast for 8 weeks
What are the associated injuries with a perilunar dislocation of lunate?
Fractured waist of scaphoid and dorsal capitate dislocation
What are the complications of not having urgent surgery with a perilunar dislocation of lunate?
Long-term instability and radiographic wrist arthritis
A 22 year old badminton played trips during a match and falls onto an outstretched hand. They are examined in A&E and found to have no swelling, with tenderness 2cm distal to Lister’s tubercle, Watson’s test is positive. What is the most likely diagnosis?
Scapholunate dissociation
What is the most appropriate imaging for a Scapholunate dissociation and what are the x-ray findings?
Stress films - clenched fist PA view
Scapholunate gap
What is the management of Scapholunate dissociation?
Open reduction and reconstruct ligaments plus temporary internal fixation
What is the complication of Scapholunate dissociation?
SLAC wrist (Scapholunate advanced collapse)
A 21 year old gymnast presents with gradual onset wrist pain and reduced range of motion. On examination there is some central dorsal wrist swelling with pain on palpation in this area. Their x-ray shows a negative ulnar variance. What is the most likely diagnosis?
Kienbock’s Disease
What is the conservative management for Kienbock’s disease if <3 months from onset?
Restrict high-level impact loading.
Prolonged casting and persistent radiology follow up
What surgical procedure is offered for Kienbock’s’s disease?
Radial shortening osteotomy - results in slightly reduced grip strength
Salvage procedures are required for advanced cases due to carpal collapse
What mechanism (and sport) predisposes Scaphoid Impaction Syndrome?
Repetitive hyperextension stresses (weight-lifting/gynmastics)
What mechanism (and sport) predisposes Triquetrohamate Impingement Syndrome?
Forced wrist extension and ulnar deviation (racquet sports/gynmastics)
What mechanism (and sport) predisposes Radial Styloid Impaction Syndrome?
Repeated forced radial deviation (golfers)
What impingement syndromes are predisposed by repetitive hyperextension stresses on the wrist?
Scaphoid Impaction Syndrome
Avascular necrosis of capitate
What is the typical presentation and management of wrist impingement syndromes?
Localised tenderness
Rest and protective brace. Occasionally CSI and surgery
When would fixation be required for an ulnar styloid fracture?
When there is distal radio-ulnar joint instability
A golfer presents with sudden onset ulnar wrist pain after hitting the ground during his swing. He has pins and needles in the medial 4th and 5th finger with reduced grip strength. On examination he is tender 3cm distal to the pisiform on the volar surface. What is the most likely diagnosis?
Hook of hamate fracture
What imaging is used for a hook of hamate fracture?
CT and MRI
What is the initial management of a hook of hamate fracture?
Immobilisation for 4 weeks
What is the management if a hook of hamate fracture fails to heal after immobilisation for 4 weeks, and how long till RTS?
Excision of hamate then 3 weeks immobilisation.
RTS 6 weeks after surgery
What are the first and second most common carpal fractures?
- Scaphoid
- Triquetral
What are the different types of triquetral fracture and which is more common?
- Body
- Cortical, dorsal flake (93%)
A 23 year old relay runner trips during a baton exchange and lands on their hand in forced ulnar deviation and dorsiflexion. They present to A&E with wrist pain; on examination they have point tenderness over the dorsal wrist on the ulnar side with painful wrist flexion. What is the most likely injury?
Triquetral fracture
What imaging is used for triquetral fractures?
XR or CT
What is the management for a triquetral flake fracture?
Soft tissue injury
Cast for 3-4 weeks to prevent instability then graded ROM and removable splint.
Full function at 8 weeks
What is the common complication and management of a triquetral body fracture?
12-25% associated with perilunate fracture dislocation
Surgical management with pins/compressive screws if displaced or concomittent injury
A track athlete trips and falls backwards onto an externally rotated, dorsiflexed and supinated hand and has severe sudden onset pain. On presentation to A&E they have bruising and swelling around the ulnar side of the wrist with pain on palpation. When testing movement they have pain at end range pronation and supination. What is the most likely injury?
Lunotriquetral dissociation
Also presents with painful ballotment and pain on pronated grip.
Relief with posterior displacement of pisiform
What is the management of lunotriquetral dissociation and how long is recovery?
Conservative management acutely (preferred to surgery)
Splint/cast for 6 weeks then gradually wean + ulnar strengthening
Recovery takes 6 months
A gymnast presents with ulnar sided wrist pain which is worse when practicing their floor routine. They have tenderness and mild swelling over the dorsal ulnar wrist and pain on resisted dorsiflexion and ulnar deviation. When testing movement there is clicking of the wrist. Their grip strength is weaker than the unaffected side. What is the most likely diagnosis?
Triangular Fibrocartilage Complex Tear
What signs and tests assist in the diagnosis of TFCC tears?
+ Foveal sign
+ Press test
+ Ulnar grind test
- ECU Synergy test (rules out ECU tendonitis)
What is the gold standard investigation for TFCC?
Arthroscopy (allows excision of torn cartilage)
What x-ray finding is associated with TFCC?
Positive ulnar variance
What is the management of TFCC after arthroscopy (and excision of torn cartilage)?
Immobilisation then graded ROM and grip strength (strengthen flexors to reduce hyperextension)
What is the conservative management of a TFCC tear?
Short period of splinting then strapping and stabilisation exercises (ECU and PQ)
What is the mechanism of onset of distal radioulnar joint instability?
Subluxation of the ulnar head occurs because of avulsion of dorsal and palmar radio-ulnar ligaments
What is the mechanism of injury in a dorsal ulnar subluxation leading to DRUJ instability?
Associated with a tear of the volar radioulnar ligament due to repetitive/forceful pronation in contact sports, tennis or gymnastics
What is the management for DRUJ instability?
Repair of TFCC
What is the typical presentation of wrist tendinopathy?
Tenderness, swelling and crepitus
What is the management of wrist tendinopathy?
Biomechanics, progressive strengthening and functional rehab
What is the mechanism of acute ECU tendon subsheath injury?
Hypersupination and flexion
What is the mechanism of gradual onset ECU tendon subsheath injury?
Repetitive forearm supination, wrist flexion and ulnar deviation
A golfer presents with ulnar sided wrist pain which is worse when swinging his golf club. There is no pain on press test. When he supinates his hand there is an audible flick. What is the likely diagnosis?
ECU Tendon subsheath failure/tendon subluxation
What is the management of ECU subluxation if the tendon is intact?
Splint in radial deviation, extension and in neutral-pronation. If there is no improvement extend cast to elbow.
Splint should be worn for 1-4 weeks followed by strengthening and taping
What is the management of ECU tendon rupture and time to RTS?
Surgical reconstruction. RTP in 3 months
A 45 year old golfer complains of burning volar wrist pain with tingling over the thumb, index and middle finger. It’s disturbing their sleep. What is the most likely diagnosis?
Carpal tunnel syndrome
What signs are used to diagnose carpal tunnel syndrome?
Tinels sign
Phalens sign
What investigation can be used to confirm carpal tunnel
Nerve conduction studies
What is the management of carpal tunnel syndrome?
NSAIDs and splinting
CSI may provide relief
What condition is it important to screen for in someone newly diagnosed with Carpal Tunnel syndrome?
Diabetes
What is the management of persistent carpal tunnel syndrome?
Open/endoscopic surgery
Where is the Ulnar nerve compressed in Hypothenar hammer syndrome?
Guyon’s canal
A 24 year old cyclist presents with wrist pain and paraesthesia in the little finger and ulnar side of ring finger. They have started to notice their grip is slightly weaker on this side. What is the likely diagnosis?
Ulnar nerve compression (Hypothenar hammer syndrome)
What is the management of Hypothenar hammer syndrome (ulnar nerve compression) in a cyclist?
Splint the wrist, NSAIDs
Change bike set up: assess grip position and move saddle back
Surgical exploration may be required
What are the different types of fracture to base of 1st metacarpal?
- Extra-articular transverse fracture of base of 1st MCP ~1cm distal to joint
- Bennett’s fracture/dislocation of 1st MCP
What is the typical presentation of an extra-articular transverse fracture to the base of the 1st metacarpal?
Thumb lying flexed across the palm
What is the typical mechanism of injury and presentation of a Bennett’s fracture/dislocation?
Result of axial compression
main shaft of metacarpal is pulled proximally by APL
What is the management of an extra-articular transverse fracture to the base of 1st metacarpal?
Immobilisation in short arm spica cast or internal fixation
IF allows anatomical reduction and early ROM
What is the management of a Bennett’s fracture/dislocation in both recreational and professional athletes?
Recreational athletes: Closed reduction and wire fixation. Cast for 4-6 weeks
Professional athletes: Anatomical reduction, plate fixation and early active movement
What is a 4th and 5th metacarpal fracture commonly known as?
Boxer’s fracture - typically from a punch
What is the typical presentation of a 4th and 5th metacarpal fracture?
Flexion deformity of distal fragment and extra dorsiflexion at metacarpal phalangeal joint which results in little functional disability
What is the acceptable amount of angulation and rotation of a 4th and 5th metacarpal fracture?
30 degrees angulation
No rotation
What is the acceptable amount of angulation and rotation of a 2nd and 3rd metacarpal fracture?
Angulation <10 degrees
No rotation
What is the management of a 2nd to 5th metacarpal fracture?
Splint/cast in 70 degrees flexion of the MCPJ for 2-3 weeks (prevents shortening of collateral ligaments + stiffness
Surgery if contact sport for faster RTP
What is the return to play time after a 2nd to 3rd metacarpal fracture for contact and non-contact sports?
Non-contact: Immediately in splint
Contact: 1-2 weeks after strong plating
What type of 2nd-5th metacarpal fractures require reduction and fixation?
Shortened, rotated, intra-articular fractures, contact sports for faster RTP
What are the clinical signs of rotation in a 2nd-5th metacarpal fracture?
Crossing of metacarpals on examination (don’t use x-ray) and reduced grip
What is the management for an undisplaced proximal phalanx fracture?
Weekly x-rays to r/o movement
Buddy strapping/ pin for early ROM
What is the management for an unstable or rotated proximal phalanx fracture?
Unstable: surgery
Rotated: ORIF
Splint for 3-4 weeks: wrist extension, metacarpal flexion, IPJ extension
What is the typical mechanism of injury for a distal phalanx fracture?
Usually a crush injury, e.g. finger jammed between fast ball and stick/bat
What is the usually management of a non-displaced distal phalanx fracture?
Splint with compression dressing
What is a common complication of a distal phalanx fracture?
Subungual haematoma (pain +++)
What is the management of a distal phalanx fracture with subungual haematoma?
Exploration and incision. Requires surgical repair to prevent nail bed deformity.
Then immobilise for 5-6 weeks in 30 degrees of MCP flexion
What is the immobilisation position for a distal phalanx with subungual haematoma after surgery?
30 degrees MCP flexion
What is the management for an osteochondral fracture of the distal phalanx?
ORIF
What fractures typically occur in the middle phalanx?
Oblique or transverse
What is the typical finger position after a fracture to the middle phalanx which is distal to the flexor tendon attachment?
Flexion of proximal fragment and extension of distal fragment
What is the management of a stable middle phalanx fracture?
Immobilise in a splint for 3 weeks in 70 degrees MCPJ flexion and 0 degrees PIPJ flexion
What is the management for an unstable or intra-articular middle phalanx fracture?
ORIF with ROM exercises as soon as fixation is stable (avoid stiffness)
What is the mechanism of injury in a volar plate avulsion fracture?
PIPJ hyperextension injury or after subluxation or dislocation
What is the management of a PIPJ volar plate avulsion fracture?
May need excision of fragment and volar plate arthroplasty followed by early mobilisation
What is the best imaging modality and management of a CMCJ subluxation?
x-ray
Splint temporarily
Reduction and pinning acutely
Fusion if chronic
Which finger and carpal bones are usually affected in CMC joint subluxations?
Usually index and middle finger to trapezoid and capitate
Which fingers are usually affected in a MCPJ dorsal dislocation?
Usually index finger or thumb
What is the mechanism of a MCPJ dorsal dislocation?
Metacarpal head pushed through volar plate of MCPJ - caught between Lumbricals and long flexor tendons (button holing)
What are the typical examination findings of MCPJ dorsal dislocation?
Hyperextension of MCPJ with ulnar deviation of finger (overlaps adjacent finger)
What is the management for a dorsal MCPJ dislocation?
Reduce (increase deformity and push proximal phalanx through volar plate (may need OR)
Dorsal splint for 5-6 weeks with 30 degrees of MCP flexion - allows full flexion but prevents last 30 degrees of MCP extension
What is the management of a dorsal MCPJ dislocation with osteochondral fracture?
ORIF
MRI of collateral ligaments
What is the most common hand dislocation?
Dorsal PIPJ dislocation
What is the MOI of a dorsal PIPJ dislocation?
Hyperextension and longitudinal compression - typically ball sports
Which ligaments are damaged in a dorsal PIPJ dislocation?
Volar plate and at least one collateral ligament
What is the management for a stable PIPJ dorsal dislocation?
Buddy strapping
What is the management for an unstable PIPJ dorsal dislocation?
Splint in flexion 10 degrees beyond the point of instability and gradually extend over 3-4 weeks
What ligaments are damaged in a volar PIPJ dislocation?
Almost always at least one collateral ligament
What is the management for a volar PIPJ dislocation?
Resistant to closed reduction
Surgery then splint in extension for 6 weeks allowing DIPJ ROM
What is the most likely complication of a volar PIPJ dislocation?
Boutonnière deformity
What is the usual MOI for a DIPJ dislocation?
Bal hitting top of finger and forcing hyperextension
What injuries and complications are associated with a DIPJ dislocation?
Volar skin laceration
Avulsion fracture
Mallet finger
What is the management of a DIPJ dislocation?
Traction and flexion. Usually stable after.
Splint for 3 weeks in 10 degrees flexion
What injury is known as gamekeeper’s or skier’s thumb?
Ulnar collateral ligament sprain
What are the consequences of an ulnar collateral ligament sprain?
Reduced hand strength and precision
Unable to perform pinching tasks (e.g. holding a key)
A hockey player falls and lands awkwardly holding their stick and presents with pain in their thumb. There is laxity in the ulnar side of the thumb at 30 degrees. What is the likely diagnosis?
Ulnar collateral ligament sprain
What is a complication of an UCL sprain in the thumb and appropriate management for this complication?
Steiner lesion.
Surgical repair is mandatory
RTP 2 weeks after surgery
What is the management of an incomplete tear of the UCL in the thumb?
Splint hand in a hand-based thumb spica, with thumb MCPJ in slight radial deviation for 6 weeks then gradually wean.
Strengthening at 8-10 weeks
What is the management of a complete UCL tear in the thumb?
Surgical repair for complete tears. Splint after
RTP 2 weeks after surgery
A muay thai athlete took a blow to the hand during sparring, knocking their thumb towards them. On review they have pain on gripping and stiffness in the thumb. On examination there is 20 degrees of laxity on ulnar deviation vs the uninjured side. What is the likely diagnosis?
1st MCPJ Radial Collateral Ligament sprain
What is the conservative management of a 1st MCPJ RCL sprain?
Spica splint for 6 weeks with extended taping then returning to sport
What is the management of 1st MCPJ RCL sprains with large tears with volar subluxation or chronic pain?
Surgery then splint for 4-6 weeks
Protection for 2-3 months
What is the management for a 1st MCP capsular sprain?
Active rehab and protection of joint from hyperextension
Thermoplastic brace over dorsal MCPJ
What is the mechanism of injury for a 1st MCP capsular sprain?
Hyperextension injury
How do you differentiate between partial and complete PIPJ collateral ligament sprains?
Partial: Painful but stable
Complete: Marked instability with lateral stress
What is the management of a stable PIPJ sprain?
Splint for 10 days with PIPJ in neutral then buddy taping, reduce swelling and active ROM exercise
How do you manage an unstable PIPJ sprain?
Splint in 10 degrees flexion greater than the point of instability. Gradually increase over 3 weeks
Can do surgical repair but conservative also adequate
What are the complications of a PIPJ volar plate injury without dislocation?
May heal normally
May have pain and a lax volar plate, repeated sprains and arthritis
How do you manage a PIPJ combined volar plate and collateral ligament tear?
“Windscreen wipe effect”
Needs surgical repair
What are the different types of Mallet finger?
Bony: avulsion of extensor tendon from distal phalanx
Soft: Rupture of extensor tendon, proximal to its insertion on DP
A football goalkeeper presents after a ball strikes their extended finger, forcing it into flexion. they are tender over the dorsal distal phalanx and are unable to actively extend the distal phalanx. What injury have they obtained?
Mallet finger
What imaging is required for a mallet finger and why?
X-ray to rule out avulsion or subluxation to DIPJ
When is an avulsion fracture obtained in a mallet finger injury significant?
If it is >1/3 of the joint surface
How do you manage a Mallet finger with volar subluxation?
ORIF
How do you manage a child with a Mallet finger with a fracture dislocation on x-ray?
Closed management
How do you manage an uncomplicated Mallet finger injury?
Splint DIPJ in slight hyperextension
Bony: 6 weeks. Soft: 8 weeks
Additional 4 weeks of splinting during sport/at night
Reinstate if any recurrence. Keep finger dry
What is a Swan neck deformity?
Hyperextension of PIPJ
Flexion of DIPJ
What is a Boutonnière deformity?
PIPJ flexion
DIPJ hyperextension
How do you examine a Boutonnière deformity?
Hyperextend MCPJ and ask them to extend PIPJ (unable to)
How do you manage a closed boutonnière deformity?
Extension splinting PIPJ for 6-8 weeks (continuous)
Encourage DIPJ flexion
Overnight splinting may be required
How do you manage an open Boutonnière deformity?
Reconstruction or pinning of PIPJ
Also same for chronic
A rugby player gets sudden pain in his finger when missing a tackle. He felt a snap. On examination his ring finger DIPJ is extended compared to his other fingers and he is unable to actively flex his DIPJ. What is the diagnosis and pathology?
Jersey finger
Avulsion of FDP tendon
What is the most appropriate imaging for a Jersey finger injury and what is the important finding to rule out?
X-ray - exclude avulsion
Bone fragment volar mid phalanx/PIPJ
What is the management of a Jersey finger? What is the alternative if you treat it late?
Urgent surgical repair with reattachment of FDP in under 10 days
If treated late requires a 2-stage operation with tendon graft or fusion of the DIPJ
What is the management of a volar joint laceration?
May represent a compound dislocation.
Assume it is contaminated - needs surgical debridement and repair
Risk of septic arthritis
Tetanus toxoid
A bare knuckle fighter presents with a laceration on his dorsal MCPJ obtained during a fight. What is the management?
Occurs from teeth
Assume contaminated - give immediate broad spectrum antibiotics
Do not close wound
What is the pathophysiology of trigger finger?
Tenosynovitis in flexor tendons
Impedes A1 pulley
A rock climber presented with pain in his middle finger associated with clicking and locking in flexion. What is the likely diagnosis?
Trigger finger
What is the management of trigger finger?
Splint to prevent metacarpal flexion
CSI
Surgery is persistent to release A1 pulley
A rock climber presents with severe swelling of his middle finger which is affecting his grip. It initially started as simple swelling after a long climb. What it the diagnosis?
Bow stringing
What is the pathophysiology of bow stringing?
Tear of A2 and/or A4 pulley
What is the management of bowstringing in climbing?
Wear tape/circular splints to control tension
May need surgical reconstruction
What nerve roots are affected in ERB-Duchenne palsy?
C5-C6 roots
A rugby player got stuck in a ruck with his head pulley laterally. He develops an adducted, internally rotated, extended arm in pronation. What is the diagnosis?
ERB-Duchenne Palsy
What peripheral nerves are involved in ERB-Duchenne palsy and what is the defect?
Suprascapular, axillary and musculocutaneous nerve
Waiter’s tip
What nerve roots are involved in Klumpke Palsy?
C8-T1 roots
A trapeze artist misses a jump and catches the bar with one arm putting strain on the arm but resulting in a fall. He develops a some wasting of the small muscles of the hand and a clawed hand deformity. What is the likely diagnosis?
Klumpke Palsy
A rugby player goes down after a high tackle complaining of pain in his shoulder, and diffuse weakness and paraesthesia in his arm. It starts to resolve after a few minutes. What is the likely diagnosis?
Stinger (brachial plexus injury)
What are the different mechanisms of injury of stingers?
- Traction from neck lateral flexion
- Direct blow to Erbs point
- Nerve compression from neck hyperextension and ipsilateral rotation
A rugby player develops sudden pain and paraesthesia over his right lateral forearm associated with weak elbow flexion. What is the likely diagnosis?
Brachial neuritis
What nerve root supplies the long thoracic nerve?
C5, C6 and C7
A rugby player receives a blow to the posterolateral neck and develops winging of the scapula. On examination they have limited shoulder elevation and pain. What investigation is appropriate and what is the likely diagnosis?
EMG
Long thoracic nerve injury
What nerve roots supply the suprascapular nerve?
C5 and C6
A tennis player presents with posterolateral shoulder pain and weakness. On examination they have wasting overlying the scapula with weak abduction and external rotation. What investigation is appropriate and what is the likely diagnosis?
EMG
Suprascapular nerve entrapment
A rugby player presents with posterior shoulder pain with loss of arm abduction after a blow to the armpit in a tackle. They have paraesthesia over the lateral aspect of the shoulder. What investigation is appropriate and what is the likely diagnosis?
EMG or subclavian arterogram
Axially nerve injury (Quadrilateral space syndrome)
A volleyball player presents with weak arm extension and wrist drop. They have reduced sensation over the first dorsal space. What is the likely diagnosis?
Radial nerve injury at the axilla or radial groove
A volleyball player presents with reduced sensation over the first web space. They have no motor deficit. What is the likely diagnosis?
Superficial radial nerve injury
A 12 year old rugby player presents to A&E after falling and landing on his shoulder. On examination he has a bump on his shoulder with tenderness over the distal clavicle. On x-ray there is an acromion physis injury. What is the diagnosis?
Epiphysis injury to lateral clavicle
A 14 year old pitcher presents with recurrent SCJ subluxation. They have a Beighton score of 8 and stooped posture. What is the diagnosis and management?
SCJ instability
Stretching programme
A 14 year old tennis player presents with lateral arm pain which is worse at night. They recently attended a training camp. On examination they have pain on resisted internal and external rotation.MRI shows oedema at the supraspinatus insertion. What is the diagnosis and management?
Insertional pain in rotator cuff
Rest for 6 weeks plus
Assess strength deficits
A 14 year old cricket player presents with gradual onset shoulder pain which is worse at night. XR shows widening of the humeral physis. What is the likely diagnosis and management?
Stress fracture of proximal humeral physis
Rest for 6-8 weeks. Can return to sport after there is no pain
A 17 year old gymnast presents with gradual onset shoulder pain which is starting to impact their ability to train. They are tender over the superior shoulder with swelling and a positive scarf test. What is the likely diagnosis?
Os acromiale
What is the mechanism of os acromiale?
Fusion failure of the anterior acromiale Apophysitis leading to a synchondrosis
A 14 year old gymnast presents with gradual onset wrist pain which is worse on weight bearing activities. They are tender over the dorsum of the hand with mild swelling. X-ray shows widening and haziness of the physis. What is the likely diagnosis?
Radial epiphyseolysis
What is the management of a paediatric stress injury?
Relative rest and splinting
A 12 year old pitcher presents with gradual onset pain in the medial elbow. They recently attended a training camp. they have restricted internal rotation and locking of the elbow. What is the likely diagnosis?
Little Leaguers Elbow (Chronic Apophysitis)
What is the most appropriate imaging and management of Osteochondritis Dessicans?
XR and MRI
Rest
What is the function of trapezius?
Elevates and rotated the scapula
What is the function of deltoid?
Arm abduction
Clavicular fibres flex arm
Posterior fibres extend arm
What is the function of Levator Scapulae?
Elevates the scapula
What is the function of Rhomboid Minor?
Elevates and retracts the scapula
What is the function of Rhomboid Minor?
Elevates and retracts the scapula
What is the function of supraspinatus?
Abduction and stabilisation
What is the function of infraspinatus?
ER and stabilisation
What is the function of teres minor?
ER and stabilisation
What is the function of teres major?
IR and extension of arm +stabilisation
What is the function of long head of triceps brachii?
Extension of forearm, accessory arm adduction and extension
What is the function of Pectoralis major?
Flexion, adduction and IR of arm
What is the function of subclavius?
Pulls tip of shoulder down
Pulls clavicle medially to stabilise
What is the function of Pectoralis minor?
Pulls tip of shoulder down and protracts scapula
What is the function of serratus anterior?
Protraction and rotation of scapula
What is the function of Subscapularis?
IR
What is the function of lattisimus Doris?
Adduction, IR and extension
What is the function of coracobrachialis?
Flexes the arm
What is the function of biceps brachii?
Flexor and supinator of forearm. Accessory flexor of arm
What is the function of brachialis?
Flexor of forearm
What is the function of triceps brachii?
Extension of forearm
Long-head: Extend and adduct arm
What is the function of FCU?
Flexes and adducts wrist
What is the function of palmaris longus?
Flexes wrist and resists shearing forces in gripping
What is the function of FCR?
Flexes and abducts wrist
What is the function of pronation teres?
Pronation
What is the function of FDS?
Flexes PIPJ and MCPJ and wrist
What is the function of FDP?
Flexes DIPJ and MCPJ and wrist
What is the function of FPL?
Flexes IPJ and MCPJ of thumb
What is the function of pronator quadratus?
Pronation
What is the function of brachioradialis?
Accessory elbow flexor in mid pronation
What is the function of ECRL?
Extends and abducts the wrist
What is the function of ECRB?
Extends and abducts wrist
What is the function of extensor digitorum?
Extends fingers and wrists
What is the function of Extensor Digiti Minimi?
Extends little finger
What is the function of ECU?
Extends and adducts wrist
What is the function of anconeus?
Abducts ulna in pronation
Accessory elbow extensor
What is the function of supinator?
Supination
What is the function of APL?
Abducts CMCJ and accessory extensor of thumb
What is the function of EPB?
Extends MCPJ and CMCJ of thumb
What is the function of EPL?
Extends IPJ and can extend CMCJ + MCPJ of thumb
What is the function of extensor indicis?
Extends index finger
What is the function of palmaris brevis?
Improves grip
What is the function of dorsal interossei?
Abducts II-IV at MCPJ
What is the function of palmaris interossei?
Adduction of I, II, IV and V at MCPJ
What is the function of adductor pollicis?
Adducts thumb
What is the function of Lumbricals?
Flex MCPJ and extends IPJ
What is the function of opponens pollicis?
Medially rotates thumb
What is the function of APB?
Abducts thumb at MCPJ
What is the function of flexor pollicis brevis?
Flexes thumb at MCPJ
What is the function of opponens digiti minimi?
Laterally rotates metacarpal V
What is the function of abductor digiti minimi?
Abducts little finger at MCPJ
What is the function of flexor digiti minimi brevis?
Flexes little finger at MCPJ
