B6.085 - Common Pathologic Conditions of Upper Extremity Flashcards Preview

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Flashcards in B6.085 - Common Pathologic Conditions of Upper Extremity Deck (75):
1

Dupuytrens contracture

relatively common disorder characterized by progressive fibrosis of palmar fascia with an unknown etiology

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associations with dupuytrens contracture

northern european genetics smoking drinking DM thyroid disease >50 yo M>F repetitive palmar trauma w vibration

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clinical dx of dupuytrens contracture

gradual onset begins as one or more smaller tender lumps on palm pain resolves w time, nodules thicken and contract tough bands of tissue may form may result in loss of full extension 4th and 5th fingers commonly affected

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Q image thumb

dupuytrens contracture

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tx for dupuytrens contracture

mild - padding, steroid injection

progressive - surgical removal of fibrotic adhesions, steroid injection

injection of clostridia histolyticum collagenased <50 degrees

minimal surgical lysis of adhesions has also been done 

6

mallet finger deformity

injury frequentyl acquired when attempting to catch a ball and impact causes sudden flexion of DIP of an extended finger

most common closed tendon injury of finger

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mechanically what is mallet finger

traumatic disruptio of terminal slip of extensor tendon at distal interphalangeal (DIP) joint 

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treatment of mallet finger

splinting 6-8 weeks if uncomplicated, immobilization with slight hyperextension 5-15 degrees

comlicated injuries require referral and likely surgical repair

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Q image thumb

mallet finger

 

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jammed finger 

prolonged swelling of proximal interphalangeal joint after an axial loading force

diagnosis of exlusion

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signs of more serious injury than jammed finger

deformity

significant swelling

significant bruising

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treatment of jammed finger

conservative management, early ROM important

13

trigger finger

the flexor tendon catches in what is called the first annular (A1) pully of the MCP causing a snapping, catching or locking when flexing finger

14

features of trigger finger

pain in palm at entrance to flexor tendon sheath

usually worse in AM improving throughout day

 

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risk factors of trigger finger

DM, age, female

dx is clinical 

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treatment for trigger finger

conservative - splinting, NSAIDs, modify repetitive activity

Injection of steroids

surgery if conservative fails, release of A1 pully

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Q image thumb

trigger finger

flexor tendon catches on what is called A1 first annular MCP

18

gamekeepers thumb

forced abduction of the thumb can result in rupture of ulnar collateral ligament

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exam for gamekeepers thumb

tenderness overlying the ulnar aspect of the MCP joint of the thumb 

swelling

laxity of 30-40 degrees more than the uninjured thumb measured in neutral and 30 degrees of flexion are strongly suggestive of a complete ulnar collateral ligament tear

no end point in radial deviation of the phalanx 

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test for gamekeepers thumb

stressing ulnar collateral ligament of MCP joint 

A image thumb
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treatment of gamekeepers thumb

thumb spika cast or splint

may need surgical referral if there is avulsion fracture

22

carpal tunnel syndrome

nocturnal parasthesia worsened by gripping activities like holidng a phone, gripping steering wheel, writing

weakness of grip

 

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risk factors for carpal tunnel

female

pregnancy

DM

obesity

RA

hypothyroid

24

what type of neuropathy is carpal tunnel

median nerve neuropathy

25

describe carpal tunnel as it relates to anatomy

unique anatomy of the median nerve as it passes through the "carpal tunnel", increased pressure in this confined area can lead to nerve compression and subsequent neuropathy

overuse syndromes seem to cause edema and lead to compression

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testing for carpal tunnel

tinel test (TAP) , phalen test (FLAP)

 

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what is the tinel test

test for carpal tunnel

examiner taps over the wrist at the point where the median nerve passes through 

tapping creates electric or sharp pain and tingling in hand, 50% sn 77% sp

A image thumb
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what is the phalen test

patient flexes wrists with the elbows raised and the backs of the hands pressed together for 1 minute

positive is pain or tingling in median nerve distribution

sn 68% 73%sp

A image thumb
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confrimatory testing for carpal tunnel

electromyography or nerve conduction studies

not absolutely needed until surgery is a consideration

imaging is generally not useful in providing additional information

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treatment for carepal tunnel

conservative

Night bracing

ice 

rest 

NSAIDs

steroid injections

surgical release 

sono guided techniques, open surgical 

31

ulnar neuropathy at the wrist

compression of ular nerve at wrist

clasically seen in cyclists due to pressure from handlebars

 

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treatment for ulnar nerve neuropathy

padding, gloves or handlebars

NSAIDs

Ice

33

scaphoid fracture

scaphoid most commonly fractured bone in wrist

34

avascular necrosis of proximal scaphoid

complication of even the smallest amount of displacement in scaphoid fracture

blood supply from scaphoid comes from radial artery, feeding the bone on the dorsal surface near tubercle and scaphoid waist. Because the proximal portion has no direct blood supply, nonunion caused by poor blood supply is an important complication of scaphoid fracture

35

treatment and dx of avascular necrosis of proximal scaphoid

surgical treatment recommended

can be difficult to diagnose, snuffbox tenderness most sensitive (90%)

scaphoid tubercle tenderness 87% sn, 57% sp

high index of suspicion with tenderness and negative x ray

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Q image thumb

avascular necrosis of proximal scaphoid

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Q image thumb

scaphoid fracture

38

nursemaids elbow

radial head dislocation usually due to pulling small childs arm

history is key

child with arm held limp and partially flexed

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exam for nursemaids elbow

apprehensive

inspection frequently unremarkable

palpation shows tenderness over lateral aspect (radial head)

ROM - wait until x rays

40

nursemaids elbow reduction

apply pressure at radial head

grasp wrist and apply slight traction

supinate wrist while flexing elbow to 90 degrees

41

medial epicondylitis and lateral epicondylitis

repetitive motion with either extension (lateral) or flexion (medial)

42

predisposing factors to epicondylitis

age 45-50

smoking 

obesity

43

what is the difference between tendititis and tendinosis

tendinitis is inflammation of the tendon and results from micro tears and tendinosis is a degenration of the tendons collagen in response to chronic overuse 

44

presentation of epicondylitis

pain with tenderness at insertion of tensions on epicondyle

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presentation of lateral epicondylitis

pain with resisted extension at wrist, supination of hand

 

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presentation of medial epicondylitis

pain with resisted flexion of wrist and pronation of hand

47

treatment for epicondylitis

conservative

splinting, activity modification, counterforce bracing, NSAIDs, physical therapy, surgery last resort

48

Q image thumb

A image thumb
49

describe examination of the shoulder

inspect symmetry

palpate Acromion, AC joint, coracoid, major bones

ROM

50

anatomy of rotator cuff

SItS

Supraspinatus

Infraspinatus

teres minor

Subscapularis

51

what does the supraspinatus do

inn by suprascapular n

abducts arm initially before action of deltoid

most common rotator cuff injury 

empty can test

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what does infraspinatus do 

inn by suprascapular n

externally rotates arm

pitching injury

53

what does teres minor do

inn by axillary n

adducts and externally rotates arm

 

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what does subscapularis do

inn by upper and lower subscapular nerves

internally rotates and adducts arm

push away test

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special tests for supraspinatus

empty can test

active painful arc test - moving arm through abduction, + if pain past 90 degrees

drop arm test - lowering arm from full abduction not smooth and coordinated

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special tests for infraspinatus/ teres minor

external rotation - isometric ER, patient presses against examiners hand

 

57

special test for subscapularis

internal rotation - assessed using the push off test painand weakness is positive

58

empty can test

supraspinatus test

arm held at 90 degrees of abduction and 30 degrees forward flexion. Then internally rotating completely with thumb pointing down 

pain without weakness indicates tendinopathy

pain with weakness indicates tear

59

AC separation

common injury in sports resulting in player hitting shoulder while arm is adducted wiht downard force

AC joint injuries are about 10% of shoulder injuries

60

treatment fro AC separation

Type 1-2 managed conservtively

3 judgement call

4-6 need surgical reduction and repair

61

grading AC separation

type 1 AC separation - ligament sprain, joint intact

2 - AC ligament torn, CC intact

3 - Both AC and CC torn, joint dislocated

4 - 6 - above plus displacement of distal clavicle

62

subacromial bursitis

can be from trauma, overuse, inflammatory, infection

need to differentiate infection, aspirate bursa, imaging usually not needed

 

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management of subacromial bursitis

infection - hospitalization

conservatively

64

adhesive capsulitis

frozen shoulder

condition causing pain and limited ROM of shoulder

causes largely unknown

spontaneous resolution usually

risk fx - >40, F, DM

65

3 stages and presentation of adhesive capsulitis

painful, adhesive, recovery

gradually increasing pain and stiffness without cause, initial phase can last 3-9 months. exam may have muslce spasms and decreased ROM without focal tenderness

tx - supportive and conservative

66

calcific tendinopathy

calcific tendinitis of the shoulder as an acute or chronic painful condition due to the presence of calcific deposits inside or around the tendons of the rotator cuff; more specifically, it s caused by depositon of calcium hydroxyapatite crystals commonly within the supraspinatus and infraspinatus tendons 

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exam for calcific tendinopathy

pain with active abduction, passive has minimal tenderness. Impingement less frequently positive

imaging is confirmatory

 

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tx for calcific tendinopathy

supportive, conservative 

steroid injection

ESWT can help break up calcifications

surgery for refractory causes

69

impingment

hawkins kennedy test is used to test for it as well as passive painful arc test

70

hawkins kennedy test

clinician stabilizes shoulder with one hand and the patients elbow flexed at 90 degrees then passiveley internally rotates the shoulder using the other hand. Pain is positive

71

passive painful arc test

passively raising arm in flexion while holding the shoulder from shrugging. pain is positive

72

rotator cuff tear dx and tx

may need imaging for dx (MRI)

trial of conservative treatment (rest, PT, NSAIDs, injection)

ortho referral for refractory cases

immediate ortho if acute traumatic injury with full thickness tears

73

rotator cuff exercises

once daily

start with light weights (1-2 lbs)

work up to 30 reps, warm up, ice after

A image thumb
74

supraspinatus rotator cuff tear signs

tender to palpation of subacromion tegion 

supraspinatus test (empty can)

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tx for rotator cuff injury

PT, steroid injection, surgery