Upper Limb Pathologies Flashcards
What is adhesive capsulitis?
Pain and loss of motion in the shoulder (frozen shoulder)
Give 3 conditions which are associated with adhesive capsulitis
Diabetes, thyroid disorders, previous surgery to lung and breast
Describe the 3 phases of adhesive capsulitis
Phase 1- painful, gradual onset (6 weeks-9 months)
Phase 2- stiff, extreme decrease in ROM (4-9 months)
Phase 3- thawing, gradual return of motion (5 to 26 months)
How would adhesive capsulitis be managed non-surgically?
NSAIDs, physiotherapy, steroid injections
How would adhesive capsulitis be managed surgically?
Manipulation under anaesthesia
Give 3 potential complications of adhesive capsulitis
Axillary nerve injury, rotator cuff tendon disruption, recurrent stiffness, fracture or dislocation
What type of shoulder dislocation is the most common?
Anterior dislocation
How will an anterior shoulder dislocation present?
Arm externally rotated and shoulder flattened. May see a bulge anteriorly
What x-ray views are required for an anterior shoulder dislocation?
AP and Y view
How is an anterior shoulder dislocation treated?
Closed reduction alongside period of immobilisation
Give 5 complications of an anterior shoulder dislocation
Shoulder instability Hill-Sachs lesion Bankart lesion Damage to brachial plexus Damage to axillary artery
What is a Hill-Sachs lesion?
Posterolateral humeral head compression fracture
What is a Bankart lesion?
Detachment of the anterior inferior labrum from the glenoid
What mechanism may cause a posterior shoulder dislocation?
Humeral head forced posteriorly in internal rotation as the arm is abduction. Seen in electrocution and convulsive disorders.
What will be seen on an xray of a posterior shoulder dislocation?
Absence of external rotation
Light Bulb sign (internally rotated humeral head is rounded)
Trough line sign
Loss of half moon overlap sign
Rim sign (widened glenohumeral joint >6mm)
Give 3 other injuries associated with a posterior shoulder dislocation
Reverse Bankart lesion
Reverse Hill-Sachs lesion
Proximal humerus fractures
How is a posterior shoulder dislocation managed?
Normally self-reduce, if needed can use closed reduction
How will an inferior shoulder dislocation present?
Arm will be in fixed abduction
What score is used to assess hypermobility? What is the score out of?
Beighton score- score out of 9
Describe what is involved in the Beighton score
Touch toes from forward flexion Thumb to anterior forearm x2 Little finger to posterior forearm x2 Invert elbows x2 Bend knee backwards x2
Give 3 common ways the brachial plexus can be injured
Trauma
Obstetrics
Burners and stingers (sports injury)
What nerve roots are affected in Erb’s palsy?
C5,C6
How will an Erb’s palsy present? What is the arm position known as?
Clinically the arm will be adducted and internally rotated at the shoulder, pronated and extended at the elbow
Waiter’s Tip position
What muscles will be weakened in a C5 injury?
Deltoid, Teres Minor, Supraspinatus, Infraspinatus, Biceps brachii
What muscles will be weakened in a C6 injury?
Brachioradialis, Supinator
What nerve roots are affected in Klumpke palsy?
C8,T1
How will a patient with Klumpke palsy present?
Weakness of the intrinsic muscles of the hand –> claw hand
wrist in extreme extension, hyperextension in the MCP joints, IP joints flexed
Where do most clavicle fractures occur?
Medial 1/3rd
Why are clavicle fractures always displaced?
SCM muscle pulls medial fragment posterosuperiorly
Pectoralis and gravity pull lateral segment inferomedially
When is a clavicle fracture operated on?
When the fracture is displaced
What surgical options are available for a clavicle fracture?
Open reduction and internal fixation
Closed reduction and intramedullary fixation
What is a flail chest?
3 or more rib fractures
What other injuries with a flail chest often present with?
Scapula fracture
Clavicle fracture
Pneumothorax
Haemothorax
What are the signs of a flail chest?
Paradoxical respiration
Chest wall deformity
Soft tissue crepitus
Why are scapula fractures only associated with high energy trauma?
Thick, sturdy bone
Surrounded by muscle and soft tissue on both sides
What is a SIT rotator cuff tear?
Tear of the supraspinatus, infraspinatus and teres minor muscles
When do SIT rotator cuff tears occur?
After a shoulder dislocation in elderly patients
When do subscapularis tears occur?
Acute avulsion in younger patients Iatrogenic injury (failure of surgical repair)
What are 3 risk factors for rotator cuff tears?
Older age, smoking, hypercholesterolaemia, family history, overhead throwing athlete
What are the common symptoms of a rotator cuff tear?
Pain in deltoid, night pain, pain worse when lifting arm overhead, loss of active ROM
What are the 2 blood vessels which supply the humeral head?
Ascending branch of humeral circumflex artery –> arcuate artery
Posterior humeral circumflex artery
Give 6 potential causes of avascular necrosis of the shoulder
ASEPTIC Alcohol/AIDS Steroids/SLE/Sickle cell Erlenmeyer flask Pancreatitis Trauma Idiopathic/Infection Caisson (the bends)
What classification system is used for avascular necrosis of the shoulder?
Cruess classification
What are the symptoms of avascular necrosis of the shoulder?
Pain, loss of motion, crepitus, weakness of rotator cuff and deltoid muscles
When is a hemi-arthroplasty needed in avascular necrosis of the shoulder?
Stage III and IV
Subchondral fracture
Flattening and collapse of the humeral head
When is a total shoulder replacement needed in avascular necrosis of the shoulder?
Stage V
Degenerative changes extend into the glenoid
What is a shoulder hemi-arthroplasty?
Humeral articular surface is replaced with a stemmed humeral component and a new humeral head
When is a shoulder hemi-arthroplasty contraindicated?
Infection
Neuropathic joint
Unmotivated patient
Coracoacromial ligament deficiency
What is a total shoulder arthroplasty?
Replacement of the humeral head and glenoid resurfacing.
What are the symptoms of a winged scapula?
Shoulder and scapula pain, weakness in overhead lifting, discomfort when sitting in a chair
What is the cause of medial winged scapula?
Damage to long-thoracic nerve (C5,6,7)
Can be caused by anaesthesia complications, repetitive stretch injury, compression injury, scapula fracture.
How will a medial winged scapula present?
Superior medial scapula elevates and moves medially. There is wasting of the anterior scalene triangle
What is the cause of lateral winged scapula?
Damage to cranial nerve 11 affecting trapezius muscle. It is often caused iatrogenically from general surgery or neurosurgery
How will a lateral winged scapula present?
Superior medial scapula drops downwards and lateral. Shoulder girdle appears to droop. There will be anterior scalene atrophy.
How are proximal humeral fractures classified?
Neer classification
Based on the anatomical relationship of the fragments
What are the symptoms of a proximal humeral fracture?
Pain, swelling, decreased range of motion
How may a proximal humeral fracture present?
Extensive ecchymosis on chest and arm, loss of sensation in regimental badge area, lack of brachial and radial pulses
Give 5 complications of a proximal humeral fracture
Avascular necrosis Nerve injury Malunion Nonunion Rotator cuff injury Adhesive capsulitis Infection
What is a Holstein-Lewis fracture?
Spiral fracture of the distal 1/3rd of the humeral shaft commonly associated with damage to the radial nerve.
How may a humeral shaft fracture present?
Limb shortened and in varus, may be some neurovascular deficit
What is the main treatment of humeral shaft fractures?
Coaptation splint with functional brace
Which nerve is most at risk in a humeral shaft fracture?
Radial nerve
What is a sail sign when seen on a distal humerus fracture x-ray?
Soft tissue swelling around the fracture
What are the symptoms of a distal humerus fracture?
Elbow pain, elbow swelling, numbness in arm, lack of pulses
What nerve is most at risk in a distal humerus fracture?
Ulnar nerve
What is CRITOL used for and what does it stand for?
CRITOL is used for telling a child's age from the areas of growth on an x-ray of the elbow Capitulum at 1 year Radius (head of) at 3 years Internal (medial) epicondyle at 5 years Trochlea at 7 years Olecranon at 9 years Lateral epicondyle at 11 years
In which direction are most elbows dislocated?
Posterolaterally
Give 3 complications of an elbow dislocation
Early stiffness
Neurovascular injuries
Compartment syndrome
Recurrent instability
How is a dislocated elbow managed nonoperatively?
Closed reduction and splinting
How is a dislocated elbow managed operatively?
ORIF
Capsular release
What is lateral epicondylitis?
Tennis Elbow
Overuse of the common extensor tendon which leads to tendonitis and inflammation
What are the symptoms of lateral epicondylitis?
Pain with resisted wrist extension, pain on gripping, decreased grip strength
What is the 1st line treatment of tennis elbow?
Rest, activity modification, NSAIDs, physiotherapy
Which nerve is at risk in tennis elbow?
Radial nerve
What is medial epicondylitis?
Golfer’s elbow
Overuse of the flexor-pronator origin point. Rarer than tennis elbow.
What are the symptoms of golfer’s elbow?
Pain over medial epicondyle, pain worse on forearm motion and gripping, may have tingling in ulnar digits
What is the first line treatment of golfer’s elbow?
Rest, activity modification, bracing, NSAIDs, corticosteroid injections
Which nerve is at risk in Golfer’s elbow?
Ulnar nerve
What is a Monteggia fracture?
Proximal 1/3rd ulnar fracture with associated radial head dislocation or instability
What are some symptoms of Monteggia fractures?
Pain and swelling at the elbow joint
Radial deviation of the hand
Weakness in the hand
What is a Galeazzi Fracture?
Distal 1/3rd radial shaft fracture and associated distal radioulnar joint injury.
Why do the radius and ulna commonly fracture together?
In close proximity
Interosseous membrane attaches the two bones
What are the symptoms of a radial and ulna shaft fracture?
Gross deformity, pain, swelling, loss of forearm and hand function, pain on passive stretching of the fingers
What is a Colle’s fracture?
Dorsally displaced, extra-articular radial fracture
What is a Smith’s fracture?
Volar displaced, extra-articular radial fracture
How is a distal radial fracture managed if there is no radial shortening?
Closed reduction and cast immobilisation
How is a distal radial fracture managed if there is instability, displacement, severe osteoporosis or >5mm of radial shortening?
Closed reduction and percutaneous pinning
External fixation
ORIF
Give 3 common ways the radial nerve can be damaged
Use of crutches
Humeral fractures
Saturday night palsy- leaning on elbow for long time
Give 3 clinical features of a radial nerve palsy
Weakness of forearm extension and flexion
Wrist drop
Weakness of thumb adductor and extensor muscles
Sensory loss on the dorsum of the hand
Where are the most common site to injure the ulnar nerve?
Elbow and hand
What is an ulnar claw?
Hyperextension of MCP, flexion of DIP and PIP of ring and little finger. The hand is stuck in this position.
What is the ulnar paradox?
A lesion to the ulnar nerve above the wrist will result in a less pronounced clawing even though the damage is worse because the flexor digitorum profundus is paralysed and so the DIP joints cannot flex.
What is the hand of Benediction?
Result of a median nerve palsy which causes loss of flexion at the MCP and IP joints in the lateral 3 fingers. This is because the flexor digitorum superficialis and the flexor digitorum profundus lose their innervation. If the patient tries to make a fist, their 2nd and 3rd fingers will not move.
What are the causes of carpal tunnel syndrome?
MEDIAN TRAP Myxoedema Ethanol Diabetes Idiopathic Acromegaly Neoplasms Trauma Rheumatoid arthritis Amyloidosis Pregnancy
What are the symptoms of carpal tunnel syndrome?
Numbness and tingling in radial fingers
Clumsiness
Pain and paresthesia at night
What is Phalen’s test?
Wrist volar flexion held for 1 minute will reproduce the symptoms
What is Tinel’s test?
When the median nerve is tapped the symptoms start
What is Dupuytren’s contracture?
Fibromatosis of the palmar fascia which leads to flexion deformities.
What is De Quervain’s tenosynovitis?
Inflammation of the sheath which surrounds the tendons of the abductor pollicis longus and extensor pollicis longus.
What are the symptoms of De Quervain’s tenosynovitis?
Pain on radial side of the hand, spasms, tenderness, swelling over the thumb, occasional burning sensation in the hand.
What is the major risk if someone has a scaphoid fracture and why is it a risk?
Avascular necrosis of the scaphoid. Blood supply is distally to proximally
What are some symptoms of a scaphoid fracture?
Pain, restricted pronation, scaphoid tubercle tenderness, pain in anatomical snuffbox
What is trigger finger?
Tenosynovitis caused by inflammation of the flexor tendon sheath. The inflammation causes the tendon to become stuck in the finger pulleys so the finger does not flex smoothly
How is trigger finger treated?
Nonoperatively –> night splinting, activity modification, NSAIDs, steroids
Operatively –> surgical debridement, release of pulley
What is a Boxer’s fracture?
Fracture of the 5th metacarpal usually caused by a direct blow to the hand eg. punch
What is mallet finger? What is the main cause?
Finger deformity caused by disruption of the terminal extensor tendon distal to the DIP joint. It is often caused after a traumatic, sudden forced flexion of the tip of the finger in the extended position.
What is Raynaud’s?
Exaggerated vasoconstriction of the arteries in the extremities. The fingers will go white, blue and then red and then become painful.
What is the difference between Raynaud’s disease and syndrome?
Raynaud’s disease is when there is no known cause and Raynaud’s syndrome is when there is a known cause such as SLE, RA or scleroderma.
