Upper Limbs Flashcards
What is subacromial impingement syndrome?
Inflamm and invitation of rotator cuff tendons as they pass through subacromial space resulting in progressive pain and weakness, especially abduction. Most common shoulder path.
Clin signs of SAIS? (3) subacromial impingement syndrome
Neer’s sign and test positive
Hawkins - Kennedy test positive
Painful arc 60-120 degrees abduction.
Clin signs of acromio-clavicular joint involve? (2)
Positive scarf test (cross-body adduction)
Painful arc 120-160 abduction
What causes “frozen shoulder”? (Risk factors)
Diabetes
Hypertension
Hyperthyroid
What is “frozen shoulder”
Adhesive capsulitis. Glenohumeral joint capsule contracted and adherent to humeral head.
Clinical signs of adhesive capsulitis/ frozen shoulder
Arm held to side. Loss arm swing.
Ext rotation and flexion esp affected.
Pain, stiff, decreased ROM
3 stages of adhesive capsulitis or frozen shoulder
- Painful
- Freezing
- Thawing
Clin tests for de quervain’s stenosing tenosynovitis
Finkelstein test positive
Which structures does de quervain’s tenosynovitis affect?
1st dorsal extensor compartment: tendons of extensor pollicis brevis and abductor pollicis longus.
Clinical presentation of de quervain tenosynovitis (5)
Radial wrist pain Local swelling over radial styloid region Crepitations on movement Pain with abduction wrist Grasping and pinching difficulty
Treat de quervain?
- Splint + steroid injection
2. Surgical decompression of extensor compartment 1
What is carpal tunnel syndrome?
Compression of median nerve by flexor retinaculum
3 risk factors for carpal tunnel syndrome
Diabetes
Pregnancy
Rheumatoid arthritis
Clinical presentation of carpal tunnel syndrome (3)
Early morning or nocturnal paraesthesia and thick fingers on radial side wrist
Weak grip
Late sign: Weak thumb abduction (wasting thenar MM.)
Clinical tests (3) for carpal tunnel syndrome
Phalen test
Tinel test
Median nerve compression test
What is tennis elbow?
Lateral epicondylitis. Common extensor tendon fibrosis and tendinosis due to formation of granulation tissue from microtears.
What causes tennis elbow or lat epicondylitis
Repetitive overuse wrist extensors
Clinical test for lateral epicondylitis
Mills test (palpate) (ECRB) Cozens test (pain W/ resisted wrist extension)
Name pathology: picture 3
Dupuytren’s contracture.
What is dupuytren’s contracture?
Common contraction of longitudinal palmar fascia
Where does dupuytren’s contracture most commonly occur?
4th and 5th digits.
Risk factors for dupuytren’s contractures (3)
Diabetes
Smoking
Alcohol
Clin presentation dupuytren’s contracture. Ass pathologies. (5)
Flexion contracture of 4th or 5th digits Hard, puckered nodules in palm Knuckle pads (garod nodes) Contractures medial part of sole of foot (leddharhose disease) Peyronie's abnormality penis
Clin test for dupuytren’s contracture
Hueston’s test: can’t lay palm flat on tabletop
Characteristic hand manifestations in rheumatoid arthritis (8)
Boutonnière deformity (PIP flexed, DIP extended). !
Z deformity of thumb (MCP flex, IP hyperextend) !
Swan neck deformity ( PIP hyperextended, dip flexed) ! - more debilitating, struggle to grip
Finger extensor tenosynovitis or tendon rupture
Symmetrical and bilateral
Spares DIP joints
Radial deviation wrist. !
Ulnar deviation fingers MCP !
What is pathology in picture 4
Acromioclavicular joint dislocation
3 common causes of radial sided wrist pain
Carpometacarpal arthritis
Trigger thumb
De quervain’s tenosynovitis
Characteristic hand presentations of asteoarthritis(7)
Osteoarthritic quintet:
- Heberden nodule: DIP
- Carpal tunnel syndrome
- Carpometacarpal arthritis of thumb
4 Mucinous cyst - Trigger finger
Also:
Bouchard nodule: PIP
DIP involved
Describe erb-duchenne palsy
C5/c6 lesion. Arm is internally rotated with adduction and flexion wrist. “Waiter’s tip”
Describe path picture 5
Erb-duchenne palsy
Waiter’s tip sign
How diagnose clinically rotator cuff tear
Weakness of external rotation
What is kienboch’s disease?
Compromised blood supply to lunate bone in wrist leading to sclerosis
Name the 4 components or stages of rotator cuff syndrome
1 supraspinatus impingement and tendinitis
2 rotator cuff tears
3 biceps tendinitis
4 acromioclavicular osteoarthritis
Clin Sign of long head of biceps rupture
Popeye sign
Most Common cause cubitis varus
Malunited(untreated) supracondylar fracture of humerus. “Gun stock deformity”
What is medial epicondylitis?
Golfer’s elbow. Common flexor tendon injury. Less common than lateral
Possible complication of medial epicondylitis
Ulnar nerve fallout
3 common causes olecranon bursitis
Primary: repetitive flexion- extension movements
Secondary: Gout ,Rheumatoid arthritis
Name pathology picture 6
Olecranon bursitis
Most common position of ganglionic cyst in hand
Dorsal scapholunate
What is a ganglion cyst
Most common benign tumour of hand filled with synovial fluid
Erb’s palsy injured roots
C5 C6
Klumpke palsy root lesion?
C8 T1
Describe klumpke palsy
Claw hand
C8 T1
Most common type shoulder dislocation
Anteroinferior/ anterior - 95%
Cause of most shoulder dislocations?
Force applied to extended, abducted, and externally rotated humerus
Clinical features of anterior shoulder dislocation? (4)
- painful, acutely reduced mobility, instability feeling
- Limb held in abduction and external rotation and pt leaning to affected side
- asymmetry
- loss of shoulder contours from flattened deltoid
- may see anterior bulge from head of humerus
Which nerves are most endangered by shoulder dislocation? (2)
- Axillary
* suprascapular
Sign on xray of posterior shoulder dislocation? (3)
ap-
• Light bulb sign: humeral head is internally rotated and tuberosities no longer project lateral, resulting in circular appearance of humeral head
• widened glenohumeral joint
lateral-
• head of humerus under acromion and post to glenoid fossa, disrupting Mercedes Benz sign
Name 5 methods of anterior shoulder dislocation reduction
• Zero position: Milch, modified Milch,
• lateral flexion: hippocratic!, modified Hippocratic!, traction-countertraction
• forward flexion: Stimson!, scapular manipulation , spaso
FARES
Kocher!
Cunningham method!
Good approach to shoulder reduction in anterior dislocation?
- Scapular manipulation
- Gentle traction ext rotate
- Forward elevation
- Spaso or fares
- milch
- Stimson
- Modified Hippocrates
Describe the milch technique
To reduce anterior shoulder dislocation, usually only if external rotation approach failed
• abduct the fully externally rotated arm into overhead position
• apply gentle traction in line with humerus and direct pressure over humeral head with drs thumb in axilla
Describe the Stimson technique
For reduction anterior shoulder dislocation after manual techniques failed
• pt prone, hang affected extremity off edge of bed with weight. -Start with 5 kg
• reduction in 30 min
Describe the traction countertraction technique
Method of reduction ant shoulder dislocation , need 2 people
• one person provide gentle continuous traction at wrist or elbow
• other person countertraction with sheet under axilla from opposite side of patient
Describe the spaso technique
To reduce ant shoulder dislocation.
Gentle vertical traction and external rotation in supine patient. Take 1-2 min
Describe the fares technique
To reduce ant dislocated shoulder
• pt supine with affected arm at side
• Dr grab pt wrist and gently pull to provide traction
. Arm gradually abducted while Dr continuously move arm up and down in arc of 10 cm to help relax shoulder muscles
• if shoulder not reduced by 90 degrees of abduction, external rotation is added
Describe hippocratic technique
To reduce ant dislocated shoulder
Traction-countertraction with foot in axilla. Adduct arm. (Pull towards you)
But high rate fractures, brachial plexus injury, vascular injury so last resort.
Name 5 complications supracondylar fracture
- Pin migration after CRPP most common
- infection
- cubitus valgus or varus (gunstock deformity)! caused by fracture malunion
- recurvatum (hyperextension ) - common with operative treatment of type 2 and 3 fractures)
- nerve palsy (usually resolve spontaneously ) - median (AINJ, radial, ulnar
- volkman ischaemic contraction -rare, usually caused by elbow hyper flexion casting (must cast <90) post compartment syndrome
- post-op stiffness!
- brachial artery injury, especially if displaced
Surgical neck of humerus fracture complications? (5)
- axillary nerve damage (deltoid atrophy)
* Posterior and anterior humeral artery and vein damage
Name 2 structures at risk for damage in humeral midshaft Fracture
• Radial nerve
. Profunda brachii artery
Both run in radial groove
Where on humerus does triceps insert?
Olecranon fossa.
Where on humerus does ulna articulate? (3)
• olecranon process of ulna to olecranon fossa of humerus posterior
. Coronoid process of ulna to coronoid fossa of humerus anterior
• trochlear notch ulna to trochlea of humerus
What is trigger finger?
Inhibition of smooth tendon gliding due to mechanical impingement at level of A1 pulley (at MCPJ) causing progressive pain, clicking, catching and locking of the digits
Occur when trying to extend finger, especially middle, ring and little finger
Presentation trigger finger? (3)
aka stenosing flexor tenosynovitis
. Finger lock in flexion when patient makes fist at pip j
• pain a1 pulley (at MCPJ)
• clicking/ catching
Name 5 risk factors stenosing flexor tenosynovitis
Aka trigger finger • diabetes! • Rheumatoid arthritis! • females! • age > 50! • prolonged gripping occupation
Treatment trigger finger? (3)
- First line = splinting in extension, activity modification, NSAIDs
- corticosteroid injections for finger, not thumb
• open surgical splitting lengthwise of tendon sheath if conservative treatment fail
Which sedation agent should be used for shoulder reduction?
• Analgesic: mophine 3mg
. Sedative : dormicum (midazolam - benzo) - use conservatively 3 mg
Wait 20 min before reduce attempt
If patient resist (contract deltoid), add 2 mg each and wait 10 minutes again.
How assess stability of shoulder post reduction?
- Place arm in 90° abduction and 90° external rotation
- this is weakest point of shoulder so if shoulder remains reduced = stable reduction. Place pt in collar and cuff 3 weeks and then start physio.
Name the terrible triad of the elbow
- Radial head or neck #
- coronoid process #
- post dislocation
Structure at risk in lunate dislocation
Median nerve
Treatment lunate dislocation?
Orif
What is a galleazzi fracture?
Fracture distal radial shaft with disruption of distal radioulnar joint
Mechanism of injury of galeazzi #?
- Hand foosh with axial loading of pronated forearm
* direct wrist trauma, typically dorsolateral aspect
Treatment galeazzi #?
Orif
What is a monteggia #?
Fracture proximal ulna with radial head dislocation and proximal radioulnar joint injury
Mechanism of injury of monteggia #? (3)
- Direct blow on post aspect forearm
- hyperpronation
- fall on hyper extended elbow
Treatment monteggia #?
Orif
Name 3 specific complications of monteggia #
. PIN: most common nerve injury; observe for 3 months as most resolve spontaneously
• radial head instability/redislocation
• radio ulnar synostosis (fusion)
What is a nightstick #?
Isolated # of ulna without dislocation of radial head
Mechanism of injury nightstick #?
Direct blow to forearm eg holding arm up to protect face
Treatment nightstick #?
- undisplaced: immobilisation
* displaced: orif if > 50% shaft displacement or > 10° angulation
What is a smith’s #?
- Reverse Colles
* volar displacement distal radius fracture
Name 4 specific complications of a scaphoid #
- most common nonunion/malunion (use bone graft from iliac crest or distal radius with fixation to heal)
- AVN of proximal fragment
- delayed union
- scaphoid nonunion advanced collapse ( SNAC ) - chronic nonunion leading to advanced collapse and arthritis of wrist
Scaphoid fracture treatment
Orif due to high risk AVN
Name the POP seen in picture 51 and its use
Modified shoulder splint cast, u-slab for humeral shaft #
Which carpal dislocate most frequently?
Lunate
Which carpal fracture most frequently?
Scaphoid
What is gamekeeper/ skier’s injury?
Ulnar collateral ligament injury at thumb metacarpophaleageal joint
How apply burkhalter splint?
- 30° extension at wrist, 90° flexion MCP,
- volar part splint to MCP joint dorsal to pip joints to block extension.
For proximal phalanx fracture
Identify picture 59
Stimson technique for anterior shoulder relocation
Identify picture 60 manoeuvre
Traction countertraction technique for ant shoulder reduction
Identify picture 61 manoeuvre
Spaso technique ant shoulder reduction
Label picture 62
Left: cubitis varus
Middle -normal
Right cubitus valgus
Label picture 63
See picture 64
