16 Clinical Correlation of Upper Extremity Flashcards Preview

MSS > 16 Clinical Correlation of Upper Extremity > Flashcards

Flashcards in 16 Clinical Correlation of Upper Extremity Deck (72)
1

most commonly fall directly onto shoulder
Pain with overhead motions, deformity of superior
shoulder

Acromioclavicular (AC) sprains

2

Pain with cross body adduction of arm (positive cross-chest
test)
Painful arc of abduction over 150°

Exam finding for AC sprain

3

Exam finding for AC sprain

pain with cross body adduction, painful overhead motions, deformity of superior shoulder

4

Grade I for AC

AC ligament stretch

5

Grade II for AC

AC ligament tear and coronoid-clavicular (CC)
ligament stretch

6

Grade III for AC

complete tears of both AC & CC ligaments

7

Grades IV+ for AC

complete tears + clavicular displacement

8

Tx options for AC Grades
I and II
III
IV

Non-operative – grades I & II
b) Operative grade IV+
c) Either – grade III

9

most common dislocation of shoulder

anterior dislocatoin

10


a) Forced extension, abduction and external rotation of the
arm (e.g. open arm tackle or fall onto abducted arm
b) Direct blow to posterior shoulder

Will cause anterior shoulder dislocation

11

Pt comes in with arm held in opposite hand in slight abduction and external rotation. He doesn't want to abduct his arm and doesn't want to internally rotate

Shoulder dislocation

12

What would you expect the shoulder to look like on shoulder dislocation

(1) Prominent acromion
(2) Humeral head anterior to acromion and adjacent to
coracoid

13

How can you test a patient for shoulder dislocation?

Positive apprehension test – feeling of instability with
stressing of the joint (note – feeling of pain is not a positive test; this test is done when patient is currently reduced/in normal anatomical alignment – not when dislocated)

14

What neurovascular structures should we worry about in a shoulder dislocation?

axillary & musculocutaneous nerves -sensation

15

How do we tx a non-surgical acute shoulder dislocation?

Non-operative - immobilization with sling and
watch for 3 to 4 weeks for young adult; for older adult
sling for comfort and gentle mobilization

16

When would we consider surgical measures for a shoulder dislocation?

consider for adolescent athlete and high
level athletes

17

Radiology for shoulder dislocation?

multi-planar x-rays

18

Pt comes in with pain on overhead arm movement

Rotator cuff injury

19

What 3 impingement tests can we do if we expect a rotator cuff injury?

(1) Neer’s test – pain when arm is elevated through
forward flexion
(2) Empty can test (Jobes) - arms (vertically) abducted
to 90°; 30° horizontally adducted; thumbs down to
floor; push downward to floor against resistance
(3) Hawkins Test - pain with resisted external rotation
with elbow flexed and across body

20

What is a Neers test

pain when arm is elevated through forward flexion
--for rotator cuff injury

21

What is an Empty Can test?

arms (vertically) abducted
to 90°; 30° horizontally adducted; thumbs down to
floor; push downward to floor against resistance
--for rotator cuff injuy

22

Hawkins Test -

pain with resisted external rotation
with elbow flexed and across body
--for rotator cuff injury

23

Rotator cuff weakness; patient has profound weakness when abducting their arm; may even drop it

possible complete tear of rotator cuff: via drop arm test

24

What degree of abduction is painful for rotator cuff injuries?

Painful arc of abduction (80° to 120°)

25

Tender at insertion of supraspinatus tendon on greater
tuberosity of humerus

rotator cuff injury

26

Treatment for rotator cuff injuries

a) Non-operative for small tears and tendonopathies
b) Surgical for large tear or in a younger athletic patient

27

Pt comes in complaining of painful, stiff shoulder

Adhesive capsulitis; frozen shoulder

28

Etiology of frozen shoulder -

complication of many injuries including dislocation,
rotator cuff tendinitis, reflex sympathetic dystrophy and fractures

29

What do we expect to see on exam with a pt with a frozen shoulder?

limited passive (& active) ROM – especially noted in
external rotation

30

Treatment for adhesive capsulitis

- time - often resolve in 1-2 years
(younger patients better prognosis of spontaneous resolution)

31

Pt comes in with pain on medial elbow and secondary weakness. ON exam, they state tenderness over medial epicondyle and pain with resisted wrist flexion and forearm pronation

Medial epicondylitis “golfer’s elbow”

32

Etiology of medial epicondylitis

overuse of the wrist flexors - (especially - pronator teres
and flexor carpi radialis)

33

– overuse from repetitive extension (especially - extensor
carpi radialis brevis)

Lateral epicondylitis

34

pain over lateral elbow radiating into forearm; late -
weakness

lateral epicondylitis or tennis elbow

35

Signs of lateral epicondylitis:

tenderness over lateral epicondyle; pain with resisted wrist
dorsiflexion & middle finger extension

36

tenderness over lateral epicondyle; pain with resisted wrist
dorsiflexion & middle finger extension

Lateral epicondylitis

37

Pt had a fall on outstretched hand and is experiencing tenderness in anatomic snuffbox

scaphoid frx

38

What radiology tests do we order when we expect a scaphoid fracture?

Radiology – often need to consider MRI, CT or bone scan

39

Etiology of carpal tunnel

irritation of the median nerve in carpal tunnel

40

Tingling & pain in median nerve distribution
(1) Especially at night - frequently accompanied by
numbness

carpal tunnel syndrome

41

Early Signs of carpal tunnel

a) Tinel’s sign - percussion over the carpal tunnel reproduces symptoms
b) Phalen’s sign - wrists are held in maximal flexion for 1
minute reproducing symptoms
c) Sensory loss of the radial 31/2 fingers

42

Late findings of carpal tunnel

thenar eminence atrophy and loss of 2 point discripination

43

overproduction of fluid by a joint of tendon sheath
a) Filled with thick gelatinous material

wrist ganglion

44

pt has a firm but mobile lump in her wrist, what's the tx

wrist ganglion:
a) Typically clinically observation
b) Aspiration – if painful, but often reoccurs
c) Surgery – for definitive treatment, but still may recur

45

Recommend tx for fractures

1. immobilization
2. avoid NSAIDs: may interfere with bony healing via PGs

46

Initial tx of patient with broken scaphoid

immobilization

47

What is a worry with a scaphoid frx

its a watershed region and can disrupt blood supply and become necrotic. certain areas are more sensitive to blood loss then others

48

What are the contents of the snuffbox

Radial nerve and artery; parathesis on back of thumb
Cephalic vein
scaphoid bone

49

What do we worry about with a femoral head fracture

medial circumflex supplies most of femoral head. we worry with a frx to femoral head that we will impede the blood supply from this area: key for head and neck of femur

50

Pt presents with significant crepitus, pain with motions but has almost FROM, stregth WNL and positive apprehension sign... shes 16 yo with recurrent shoulder pain and self reduced her dislocated shoulder at home

pt has arthritis (crepitus and history of dislocations) if it was rotator cuff tendinitis she wouldn't have FROM

51

What would we see in the history of pt with arthritis?

stiffness, especially after rest and worse after prolounged use

52

What would the exam findings would you expect from someone with arthritis

joint line tenderness, mild swelling, deformity, symptoms with both passive and active motions
see damage to articular cartiledge

53

Capsulitis history

Limited ROM
Painful earl with decreased ROM (freeze phase)
non-painful with stable, decreased ROM (frozen phase)
Non-painful with improving ROM (thawing phase)

54

Risk factors for capsulitis

injury, diabetes, thryoid disease

55

What to look for on MRI of capsulitis

see brighter white signal in the inferior aspect of joint capsule signifying joint inflammation

56

Tx for capsulitis

reassurance, educate and set expecation, maintain ROM and pain control
takes 2-3 years to get back to normal, keep using the arm

57

Pt hear their shoulder pop and now has a bulge in biceps area, most likely diagnosis

Long head biceps tendon rupture

58

Key signs in exam of long head biceps rupture

see a furrow by the deltiod where the tendon usually is and the bulge is more distal on the arm

59

Best tx for a tx of long head biceps tendon rupture

do nothing
Ask: what impact does missing muscle action have, are there altenative muscles, what are the functional requirements of my patient

60

disorder of muscular or tendinous bony attachment

enthesopathy; type of musculoskeletal injury

61

technically acute inflammation of tendon
--often dt a blow or pull

Tendinitis

62

chronic degenerative condition of tendon; seen with submaximal repetitive irritation

Tendinosis

63

Pt presents with pain in left elbow, got hit with golf ball, has 2 cm area of pain over distal humerus and lateral proximal radius.
pain persists with wrist and middle finger extension and with supination
no pain with varus or valgus stress

Lateral epicondylitis

64

Causes of Muscle strain

muscle fiber damage from overstretching:
eccentric loading (muscle lengthening during firing)

65

Syptoms of muscle strain

stiffness, bruising, swelling, soreness

66

What situations are NSAIDS most favorable

Acute patellar tendinitis

67

Pt fell right onto shoulder. Has pain with overhead motions and deformity of superior shoulder.
On exam has pain and deformity of AC joint, pain with cross body adduction of arm and painful arc of abduction over 150 degrees

Acromioclavicular (AC) sprain

68

Microscopic damage with no increased laxity, but pain with stress

Grade I Sprain

69

Partial tear with increased laxity and pain

Grade II sprain

70

Complete tear with significant laxity

Grade III sprain

71

What structures do we worry about getting damaged in anterior shoulder dislocation?

Axillary nerve: deltoid is innervated by axillary so check for abduction past 30 degrees (supraspinatous does first 30 degrees of abduction)
also have the musculocutaneous: check skin over deltiod and the skin on arm

72

What is our most effective passive stabilizer

vacuum phenomena