Upper limb Flashcards
signs of shoulder impingement
painful arc
Hawkins sign
decreased ROM
pain on movement, not usually at night
Bigliani grade 3 acromion = ____
can cause shoulder ___
slopes closer to humerus
impingement
management of shoulder arthritis is ___
conservative
Sx is risky and not as reliable as lower limb Sx
Hill-Sachs lesion =
dent in back of humerus head as impacts on front of glenoid
TUBS (shoulder instability) =
Rx =
Traumatic Unilateral dislocation with Bankart/Hill-Sachs lesions
Bankart repair - anchor and suture labrum back to bone
AMBRI (shoulder instability) =
Atraumatic Multidirectional Bilateral Rehab Inferior capsular shift
carpal tunnel syndrome is compression of ____
Ix =
Rx =
median nerve
nerve conduction
night splints, Sx decompression
cubital tunnel syndrome is compression of ___
ulnar nerve
3 sites where ulnar nerve can be compressed =
FCU tendon heads
cubital tunnel
intermscular fibrous bands above elbow
in upper limb trauma get at least __ views on xray
2
where >2 views are needed in upper limb trauma = (2)
C1-2 = AP, lateral and odontoid peg (teeth parted) Scaphoid = AP, lateral and 2 obliques
appearance of haematoma in # on xray =
lucency crossing bone
avulsion fractures mechanism =
tendons pull bone off
appearance of avulsion fractures on xray
mimic =__+__+__ = all ___
incompletely corticated fragment sesamoid bones accessory ossification centres old non-united #s all completely corticated
normal alignment of acromioclavicular joint on imaging
inferior border of clavicle has a straight line to inferior border acromium
alignment of humero-capitellar joint on imaging
used to spot __
anterior border of humerus should go through middle of capitellum
supracondylar #
in lateral wrist ___ should look like a cup
lunate
if there is an elbow effusion a displaced ___ can be seen posterior to ____ = ___ sign
is always abnormal if present
fat pad
distal humerus
posterior fat pad
in children: fracture that causes usually smoothly curved metaphyses to be bumpy on imaging =
buckle
3 types of # seen in kids
buckle
plastic bowing
greenstick
Little leaguers elbow =
medial epicondyle of humerus avulsed due to flexor tendons
bony rings where you would expect to fin >1 fracture
spinal canal
pelvis
forearm
lower leg
extra articular fracture of the distal radius with dorsal angulation and impaction =
mechanism of injury =
Colles #
FOOSH
50% of Colles # also have a ___ #
ulnar styloid
hand is displaced ___ in a Colles #
backwards
pain in anatomical snuff box after FOOSH =
scaphoid #
best view on imaging for posterior shoulder dislocation =
oblique view
involving articular surface of 1st MC base - tendons pull thumb distal to # = displacement =
Bennett’s #
age commonly affected by supraspinatus tendonitis
35-65 yo
age typically affected by frozen shoulder
more common in ___
40-60yo
diabetics
if shoulder pain can be localised with one finger it is ___ and is likely to be ___ pathology
superficial
ACJ OA/pathology
if shoulder pain is generalised it is likely to be from ___ structures eg __/__
deeper
subacromial
GHJ
Scarf test puts P on
ACJ
Hawkins is for __ pain - impingement as rotate ___ upwrds
subacromial
greater tuberosity
sternoclavicular joint arthritis is ___
Rx =
rare
physio, injection (rarely excision)
ACJ arthritis is __ and often overlaps with ___
Rx =
common
impingement
injection / excision
causes of GHJ arthitis
idiopathic (most common)
previous Sx
instability
cuff tear
distinctive candle drip osteophyte of ___ =
humerus
GHJ OA
OA of GHJ causes decrease of ROM esp __
external rotation
if rotator cuff is torn ___ pulls humeral head __
deltoid
superiorly
new Rx for cuff tear
reverse geometry replacement
fossa olecrani is a feature of
elbow OA
if elbow replaced wt limit is
5kg / 1kg repeatedly
Sx options for RA
synovectomy
tendon realign
replace
fuse
SLAC =
scapholunate advanced collapse (=> wrist instability)
SNAC
scaphoid non-union advanced collapse
total wrist arthrodesis stops __ movement but preserves ___
flexion/extension
sup+pronation
base of thumb OA is usually the __ joint affected in OA => ___ subluxation and pain esp in __
2nd
CMCJ
pinch
volar plate of PIPJ becomes attenuated, small ligs and lumbrical tendons move dorsally =
swan neck deformity
PIPJ flexion and DIPJ hyperextension = ___ deformity
Boutonniere
outpouching of synovial fluid from DIPJ OA
mucous cyst
Rx of mucous cyst
usually leave alone
rarely = Sx
possible complications of mucous cyst
pain
fluctuate/ discharge
deform nail = a ridge
outpouchings of synovial cavity, filled with synovial fluid, fluctuate, usually painless/”tight” and resolve with time
affect the hand
ganglion cyst
in trigger finger tendon swells and catches on __ pulley so there is pain over the ___ and finger is stuck in ___
A1
MC head
flexion
Rx for trigger finger
spontaneous resolution >
splint >
steroid and LA injection (can repeat up to 3x - usually curative)
Sx to divide A1 pulley
spontaneous, very painful, swollen and red
+ve Finklesteins test - thumb in fist and ulnar deviate => v painful =
Dequervains tenosynovitis
Rx for Dequervains tenosynovitis =
NSAIDs, splint, rest, steroid injection, decompression Sx
thickening and contracture of subdermal fascia => fixed flexion =
Dupuytrens contracture
high incidence of Dupuytrens contracture in which population
N Europeans
dupuytrens contracture usually starts as __/___ and starts ___+__
palmar pit/nodule
painless and gradual
Dupuytrens diathesis is ass with __+__
Lederhosen’s
Peyronies
risk factors for development of Dupuytrens contractures
northern european DM alcohol/cirrhosis smoking epilepsy trauma knuckle pads; Ledderhose; Peyronie’s; frozen shoulder
Dupuytrens affecting __ joint is likely to do well
___ is unlikely to ever fully flex as capsule thickens
MCPJ = good
PIPJ
Rx for Dupuytrens contracture
activity modification > fasciectomy dermofasciectomy collagenase injection (stretch next day and itll snap easily) percutaneous needle fasciotomy
paronychia =
nail fold infection
Rx of paronychia
elevate
abx
incise and drain
flexor tendon sheath infection: occurence rate? is a Sx \_\_\_\_\_ can\_\_\_\_ the palm and arm very \_\_\_ limited passive and active \_\_\_ may cause \_\_\_\_\_
rare Sx emergency track up painful extension tracking lymphangitis
Rx for flexor tendon sheath infection
incision above and below and wash out sheath
If pressure from a subungual haematoma is causing pain then Rx =
trephine (bore a hole in nail)
if the tip of the finger/ nail has been severed Rx =
dressing
if the finger has been severed halfway through the length of the nail Rx =
repair nail bed and stabilise bone
if there is less than 5mm of nail bed left after finger has been severed then Rx =
ablate
If MCPJ needs immobilised then do in ___ because this is when the capsule is ___ so don’t lose ROM
flexion
tight
If PIPJ needs immobilised then do in ___ because this is when the capsule is ___ so don’t lose ROM
extension
tight
is easier to see rotational of the fingers if you ask the ptnt to ___
flex them
Boxer’s # =
fracture of one of the MC in the hand usually after a drunken swipe
minimally displaced and no rotation
Rx for Boxer’s (MC) #
buddy strap and mobilise early
Mallet finger is caused by
extensor digitorum tendon of the fingers becoming unattached or having an avulsion fracture that causes the DIPJ to become flexed permanently
s+s of Mallet finger
can’t extend DIPJ
tender and bruised
Rx of mallet finger
splint 24/7 for 6 wks
fix if large avulsion #
is chronic/ present late = dermatotenodesis
Rx of early and late presentation of PIPJ dislocation
early = pull to reduce and buddy strap late = fusion
Bennett’s # causes the fragment of thumb base attached to hand lig.s to ___ and the rest ___
stay in place
displaces
can tell if someone has a tendon injury if when they lie their hand volarly ___
fingers dont naturally flex
tendons present at the distal 1/3 of fingers =
FDP
tendons present in the proximal 2/3 of fingers and tip of distal palm
fds + fdp in same sheath
in the middle of the palm the tendons are/ arent in a sheath
arent
at the base of the palm lies the ____ ligament
transvere carpal
to test FDP tendon =
hold just below DIPJ straight and flex DIPJ
to test FDS
hold other fingers and ask ptnt to flex PIPJ - it acts independently whereas FDP work together
Rx of tendon injuries of the hand =
Sx repair
mobilise early so no stiffness
eschar =
thick leathery inelastic skin post burn
mutilating injuries of the hand = ___ early and leave ____ for ___wks to decrease infection risk
debribe
uncovered 2-3wks
chronic tendon injury with damage to tendon ECM =
tendonosis
predominant cells in tendon =
90% is __
fibroblasts
type 1 collagen
arrangement of fibres in a tendon =
___>__>___> fascicle
microfibrils
subfibrils
fibrils
fascicle
fascicles in tendons are separated by ___ and covered by ___
separated by endotenon
covered in epitenon
blood supply to tendons = ++_
perimyseum
periosteal tendon insertion
paratenon
histological degeneration of collagen and ECM =
tendonosis
tendonosis is caused by increased ___ most likely
these increse with __+__
MMPs
age and repetitive strain
tendonosis can be __ and usually occur where there is a ___
painless
poor blood supply
most tendon injuries settle with ++_
rest, analgesia and anti-inflammatories
cortisone/anaesthetic can be used in + tendon problems but NOT __ or ____
rotator cuff and tennis/golfer’s elbow = fine
NOT achilles or extensor knee mechanism
Rx for achilles tear =
splint/cast
__+___ tendon problems can be treated with decompression
supraspinatus tendonitis
subacromial tendonitis
synovectomy is used to prevent rupture in ___+__
RA of extensor wrist tendons and tibialis posterior
tendon transfer can be used to treat __+__ tendons
tibialis posterior and extensor pollicis longus
most common rotator cuff muscle to be injured =
supraspinatus
s+s for rotator cuff tear
achy pain down arm that gradually increases difficulty sleeping on affected side \+ve impingement signs hard to reach overhead+lift painful arc/weakness
Rx for rotator cuff tear
conservative = rest physio and injections Sx = repair and subacromial decompression
gold standard test for rotator cuff tear =
___ scan can also detect ___
US - dynamic scan can also detect impingement
biceps tendinopathy tends to occur where ___ passes through ___ on ____
long head
bicipital groove
anterior humerus
s+s of biceps tendinopathy
anterior shoulder pain
elbow pain that is worse on shoulder flexion, forearm pronation and elxbow flexion
click/snaps with shoulder movement if subluxed
scan for biceps tendinopathy =
US
popeye sign + extensive bruising =
biceps tendon rupture
Rx for biceps tendinopathy
conservative
Sx (high risk of neurovasc complications)
s+s of leteral epiconylitis (Tennis)
pain and tender and lat epicondyle greater when muscles stretched
pain with resisted extension of middle finger
Mills test +ve
Mills test for lateral epicondylitis =
palpate ptnt’s lateral epicondyle with thumb while passively pronating forearm, flexing wrist and extending elbow
+ve test = reproduction of pain near the lateral epicondyle
lateral epicondylitis is non ___
non-inflammatory
avoid injections for medial epicondylitis (Golfers) because ___
is near the path of the ulnar nerve
s+s of medial epicondylitis (Golfers)
pain greater on wrist flexion and pronation, also greater on grasping
some ass with ulnar neuropathy
Rx of medial and lateral epicondylitis
usually conservative
Sx release is last resort
DeQuervains Tenosynovitis affects \_\_\_ containing \_\_+\_\_\_ pain over \_\_\_\_ F:M age ass with \_\_+\_\_
1st extensor compartment APL and EPB radial styloid process F>M 30-50yo preg and RA
test for DeQuervains Tenosynovitis
Finklesteins test - thumb in fist and ulnar deviate hand => pain
__+__ DeQuervains Tenosynovitis to rull out CMC OA
US xray
Rx for DeQuervains Tenosynovitis
splint rest physio
analgesia
injections
Sx decompress
s+s of hand extensor mechanism rupture =
weak wrist extension and dropped finger
hand extensor mechanism rupture Rx =
tendon transfer
EPL rupture is ass with __+__
RA
post colles #
hand extensor mechanism rupture is ass with __ which causes an AI attack on __ and leads to tendon __
RA
synovium
transfer
Rx of EPL rupture that is causing loss of function
tendon transfer
___ can prevent RA causing a hand extensor mechanism rupture
synovectomy
development of trigger finger:
stenosing ___ > ____ metaplasia >nodule ____ > catches on ____ > triggering
tenosynovitis
fibrocartilaginous
FDS tendon
A1 pulley
