091014 clinical upper extr injury

Question 1

types of fracture mechanisms

Answer 1

acute fracture : suddent impact of large force exceeding the strength of bone

stress fracture : repeititive submaximal stresses

pathologic: normal forces to diseased bone

Question 2

fracture hx

Answer 2

acute-sudden blow

chronic-repetitive activity; increase in activity duration, intensity, or frequency

Question 3

fracture exam

Answer 3

deformities (if bleeding with or w/o a fragment, you should suspect open fracture, which is an orthopedic emergency. NEEDS to be washed out ASAP)

bony point tenderness (just at one spot)

pain w/ loading the bone (indirect loading is very useful-like the axial loading test, bump test, fulcrum test, hop test)

Question 4

how to treat a fracture?

Answer 4

in general, immobilization

avoidance of NSAIDs (some animal studies show NSAIDs interfere w bony healing through prostaglandins)

Question 5

fall on an outstreched hand-what are you concerned about?

Answer 5

scaphoid fracture

Question 6

bones with vulnerable blood supply

Answer 6

scaphoid
talus
femoral head

Question 7

what blood vessel supplies to scaphoid?

Answer 7

radial artery’s branch called the palmar carpal branch

Question 8

what can a scaphoid fracture cause in terms of damage?

Answer 8

can disrupt blood supply going to distal ends of scaphoid, as the fracture is usually mid-scaphoid

then you would get necrosis

Question 9

snuffbox contents

Answer 9

radial nerve
cephalic vein
radial artery
scaphoid bone (deepest)

Question 10

how would you be able to tell its a scaphoid frac?

Answer 10

if pressure on anatomic snuffbox elicits pain

can have radial nerve paresthesia

Question 11

what to do for scaphoid frac

Answer 11

need to put on splint b/c these fractures (due to tenuous blood supply) won’t heal very well if you don’t protect them. if it were a sprain, you may just watch and observe, but here, it’s critical to immobilize

can follow w/ MRI to see the blood supply

Question 12

which artery supplies the femoral head?

Answer 12

medial circumflex femoral artery

Question 13

with full range of motion, you can rule out

Answer 13

dislocation (w/ acute dislocation, it will be painful and the pt wouldn’t let you move it around much)

Question 14

when can you have accelerated arthritis at an early age?

Answer 14

with trauma (ex-with repeated dislocations, articular cartilage will be damaged and worn away)

Question 15

arthritis pt hx

Answer 15

stiffness, especially after rest

worse after prolonged use

Question 16

exam findings of arthritis

Answer 16

joint line tenderness
mild swelling
deformity

KEY: symptoms with BOTH passive and active mvmt

Question 17

physical therapy may be good for arthritis b/c

Answer 17

teaches how to use body in right manner

and also, build stronger muscles so can absorb shock better

Question 18

what can you use for OA?

Answer 18

cortisone (for acute flares, or if someone has special occasion coming up)-can cause chondrocyte cell death though

NSAIDs

surgical replacement

physical therapy

dietary supplements (glucosamine, chondroitin-they make up articular cartilage)

viscosupllement (injections w/ hyaluronic acid, a building block of articular surface)

Question 19

frozen shoulder is due to

Answer 19

capsulitis (joint capsule thickening, giving rise to inflam and scarring)

Question 20

cause of capsulitis

Answer 20

idiopathic or post injury

Question 21

capsulitis hx

Answer 21

limited range of motion (hurts to raise arm overhead)

early stage: painful w/ decreased ROM (freeze phase)

then later, frozen phase: non painful with decreased ROM

then later, thawing phase: non painful with improving ROM (the condition reverts on its own)

Question 22

capsulitis exam findings

Answer 22

decreased ROM
gradually tightening endpoint
otherwise consistent with underling etiology

Question 23

diagnosis of adhesive capsulitis

Answer 23

difficult w/o clinician giving background; usually radiology can say it’s consistent with but not that this IS capsulitis

Question 24

capsulitis treatment

Answer 24

maintain ROM (what they came in with)
pain control
reassure and and educate

Question 25

popped shoulder 2 weeks ago in a construction worker two wks ago when pulling on a bolt full ROM, normal muscle strength, diagnosis?

Answer 25

long head biceps tendon rupture (refer back to picture in slides)

Question 26

differentiating btwn long head and short head biceps tendon tears at the proximal end

Answer 26

short head would result in muscle lump that is higher

Question 27

treatment of long head of biceps tendon rupture?

Answer 27

NSAIDs can be used for the pain platelet rich plasma or autologous blood injection can be used physical therapy or do nothing (can do fairly well with this)

Question 28

to cinsider when treating musclotendinous ruptures

Answer 28

impact of absence of muscle presence of alternative muscles functional requirements of pt

Question 29

enthesopathy

Answer 29

disorder of muscular or tendinous bony attachment

Question 30

tendinitis

Answer 30

acute inflam of tendon (traumatic-blow or pull)

Question 31

tendinosis

Answer 31

chronic degeneration of tendon many injuries may be acute on a chronic underlying condition

Question 32

40 year old golfer feels pain on left elbow; recently was hit by a golf ball in this area exam shows 2 cm area of pain over distal humerus and lateral proximal radius, pain with resisted wrist and middle finger extension and with supination, no pain with varus or valgus stress

Answer 32

lateral epicondylitis can't be fracture b/c it's diffuse (2 cm)

Question 33

strains usually happen with what mechanism?

Answer 33

eccentric muscle contraction

Question 34

strain is

Answer 34

muscle fiber damage from overstretching symptoms of stiffness, bruising, swelling, soreness

Question 35

for what case is the risk vs benefit ratio of NSAIDs most favorable?

Answer 35

acute patellar tendinitis NOT chronic condition (b/c less inflam there). NOT immediate post-op pain (use stronger drugs and also NSAIDs have bleeding side effect). NOT stress fracture

Question 36

with joint sprain, what can you observe?

Answer 36

pain and limited ROM

Question 37

AC sprain most commonly caused by

Answer 37

fall directly onto shoulder

Question 38

presentation of AC sprain

Answer 38

pain w/ overhead motions | deformity of superior shoulder

Question 39

exam findings of AC sprain

Answer 39

pain and deformity at AC joint pain with cross body adduction of arm (postive cross chest test) painful arc of abduction over 150 degrees

Question 40

AC injury grading

Answer 40

grade I-stretched AC ligament grade II- torn AC ligament and coracoclavicular ligament stretched grade III-torn both ligaments

Question 41

sprain

Answer 41

ligamentous damage from overloading symptoms are instability or laxity, swelling

Question 42

sprain grades

Answer 42

grade I: microscopic damage. on exam, no increased laxity but get pain with stress grade II: grossly see a partial tear. on exam, has increased laxity (opening and looseness) and pain grade III: complete tear. exam shows significant laxity.

Question 43

anterior shoulder dislocation possible sequelae

Answer 43

chip fractures in humeral head or glenoid b/c humeral head bumps into glenoid (coranoid process is in the way so it comes inferior and anterior)

Question 44

what nerve can get copmressed with anterior shoulder dislocation

Answer 44

axillary nerve (which innervates deltoids and brings sensory info from area over deltoids)

Question 45

joint stability types

Answer 45

dislocation-complete displacement subluxation-transient, partial displacement and then slips back into proper place (never loses contact with the joint) laxity-normal variant in joint looseness

Question 46

shoulder disolocation causes

Answer 46

forced extension, abduction, and external rotation of arm (open arm tackle or fall onto abducted arm) direct blow to posterior shoulder

Question 47

diff btwn ligament sprain and dislocation

Answer 47

sprain-limited ROM dislocation-won't want to move

Question 48

exam findings for shoulder dislocation

Answer 48

arm hand by opposite hand in slight abduction and exterrnal rotation asymmetry-altered shoulder contour including prominent acromion; humeral head anterior to acromion and adjacent to coracoid check sensation of axillary and musculocutaneous nerves positive apprehension test- a feeling of instability with stress

Question 49

paresthesia

Answer 49

tingling sensation

Question 50

carpal tunnel syndrome

Answer 50

median nerve problem as it goes through carpal tunnel-if have activities that increase pressure within the tunnel, resulting in nerve compression will cause paresthesia in volar aspect of hand distal thumb, index finger, middle finger, and half of ring finger

Question 51

rotator cuff injuries-why can you still ability to move against resistance?

Answer 51

b/c deltoid is still good

Question 52

rotator cuff injuries-will surgery be needed?

Answer 52

no, unless you want it. you can still have function w/o surgery if you do want surgery (like if you were an assembly line worker and needed it for repetitive work), though, it should be done soon because otherwise the muscle scars down and you can't bring it back to full length

Question 53

acute complete rotator cuff tear will present with

Answer 53

maybe some weakness initially, but w/ physical therapy, get back to function pain w/ overhead motions

Question 54

most common rotator cuff muscle tear

Answer 54

supraspinatus

Question 55

if subacromial space is obliterated, suggests?

Answer 55

rotator cuff tear