Lecture 5: UE Injuries Part 2 Flashcards
1
Q
What joints are found in the elbow?
A
- Ulnohumeral & Radiocapitellar articulation: Flex/Extend + Pronate/Supinate
- Proximal radioulnar articulation: Pronate/Supinate
a Rad Cap = radius articulates with capitellum
2
Q
Main 3 ligaments of the elbow
A
- Ulnar collateral ligament
- Radial collateral ligament
- Annular ligament
3
Q
Main 3 nerves of the elbow
A
- Ulnar
- Median
- Radial
4
Q
Main 3 arteries of the elbow
A
- Brachial
- Radial
- Ulnar
5
Q
XRAY views for the elbow
A
- AP
- Lateral
- Oblique (radcap view, 45deg): best for radial head visualization
6
Q
Interpreting elbow imaging rules
A
- Anterior humeral line should bisect middle third of capitellum
- Radcap line should pass through center of capitellum (3-4)
- Disruption may indicate fx
7
Q
Lateral Elbow XR
A
8
Q
AP Elbow XR
A
9
Q
Top 3 MC Elbow complaints
A
- Pain
- Stiffness
- Swelling
10
Q
Order of Elbow Assessment
A
- Inspect
- Palpate
- ROM
11
Q
What does flexion/supination of the elbow use? Extension? Pronation?
Muscles & Nerves
A
- Flexion/supination: Biceps, C5-C6, musculocutaneous nerve
- Extension: Triceps, C7-C8
- Pronation: Pronator teres, median nerve, C6-C7
12
Q
Describe a valgus stress test on the elbow.
A
- Tests medial ligament strength. (UCL)
- Elbow 20deg flexed with supinated forearm
- Apply pressure LATERALLY
VaL = Lateral
13
Q
Describe a varus stress test on the elbow.
A
- Tests lateral collateral ligament
- Elbow 20 deg flexed and supinated forearm
- Apply pressure from the MEDIAL SIDE
14
Q
FOOSH
A
Falling on an outstretched hand
15
Q
MCC of distal humerus factures
A
- Direct trauma
- Axial loading during FOOSH
16
Q
MC Fracture patterns seen for distal humerus
A
- Type A: supracondylar is MC in children.
- Type B: epicondylar is medial/lateral.
- Type C: intercondylar is MC overall.
Growth plate = looks like type A location
17
Q
What nerves can get injured with a distal humerus fx?
A
- Ulnar nerve: sensory + flexion/adduct of wrist, 4/5 DIP joint flexion, finger abduction
- Radial nerve: sensory + wrist extension
18
Q
How does a distal humerus fx present?
A
- Pain, swelling, tender, bruising, crepitus
- ROM limited
- Shortening if displaced fx
- Make sure to check NV status above and below!
19
Q
XRAY findings for distal humerus fx
A
- Fat pad sail sign indicates intra-articular bleeding or occult fx, MC in kids
- If you see a posterior fat pad: ALWAYS PATHOLOGIC
AP and lateral
20
Q
Type A supracondylar fx XR
A
21
Q
Type B Epicondylar fx XR
A
22
Q
Type C intercondylar fx XR
A
23
Q
Management of Type A/supracondylar elbow fx
A
- If no displacement/angulation: long arm cast at 90 deg
- If displaced/angulated/NV compromise: ORIF
24
Q
Management of type B epicondylar elbow fx
A
- Isolated, minimal displacement (< 2 mm): 90 deg splint.
- For medial condyle: Pronate forearm
- For lateral condyle: Supinate forearm
- Mod displacement (2-4mm): Perc pinning or ORIF
- Severe: ORIF
25
Long Arm Posterior Splint
Type A supracondylar fx
| If epi: you would pronate for medial, supinate for lateral
26
Top 2 MOI for olecranon fx
1. Falling on a semi-flexed, supinated forearm (avulsion)
2. Direct trauma
| Triceps contracting, yanking a piece of olecranon off
27
How does an olecranon fx present?
* Normal stuff over olecranon process
* Limited ROM
* Deformity if associated dislocation
* **MC Nerve affected: Ulnar**
28
How to image an olecranon fx?
* Start with AP and lateral views
* Radcap view if unclear or complicated
29
Management of a nondisplaced olecranon fx with minimal displacement (< 2 mm displacement)
* Long arm posterior with elbow at any deg of flexion.
* Forearm neutral
* Squeeze rubber ball 5 mins/d
* Repeat XR in **7-10 days**
30
Management of displaced olecranon fx
* Closed fx: Splint and ORIF
* Open: IV abx and consult ortho
31
CI to surgery for olecranon fx
* Elderly
* Too many comorbidities
| Sling and start ROM as pain allows
32
What is the MC fx of the elbow?
Radial Head/Neck Fx
33
What is the MOI for a radial head/neck fx?
FOOSH resulting in compression of radial head into capitellum
34
What are the 4 Mason classifications for radial head/neck fx?
1. Type 1: < 2 mm displacement
2. Type 2: Displaced > 2 mm
3. Type 3: Comminuted
4. Type 4: radial head fx + elbow dislocation
35
How does a radial head/neck fx present? (3)
* Pain/tenderness along **lateral aspect** of elbow
* **Limited ROM, esp with pronation/supination**
* +/- swelling/ecchymosis
36
What is often seen on AP and lateral views of the elbow for a radial head/neck fx?
* Fx line
* Fat pad line
| A posterior fat pad is always pathological.
37
How do we manage a Mason Type 1 Radial head/neck fx? (4)
| 1 = < 2 mm displacement
1. Sling (can be w/ or w/o posterior splint)
2. AROM after 24-48h (full extension + flexion, Pronation and supination with elbow flexed at 90d)
3. Ortho f/u in **1 week**
4. Can aspirate if hemarthorsis is blocking early ROM
38
How do we manage a Mason type 2-3 Radial head/neck fx? (2)
| 2 = > 2 mm displacement, 3 = comminuted
1. Sling + splint
2. **Ortho f/u in 2-3 days** to dicuss ORIF
39
How do we manage a type IV radial head/neck fx? (1)
| Fx + dislocation
CONSULT ORTHO IMMEDIATELY
40
What is Radial Head subluxation more colloquially known as?
Nursemaid's elbow
41
What ligament does the radial head sublux through in nursemaid's elbow?
Annular ligament
42
Who is radial head subluxation MC in?
Children **under 5 years**
43
What is the MOI for a radial head subluxation?
Pulling on a **pronated forearm with elbow extended**
| Like you're holding a kid's hand as they walk
44
Once radial head subluxation occurs, how does it present? (4)
* Arm held semi-flexed, adducted, pronated
* Refusing ROM
* Tenderness over radial head
* **No swelling or ecchymosis**
| It is not a fx, so swelling is rare.
45
Dx of radial head subluxation
Clinical
| Only need imaging if you suspect a different injury.
46
Management of radial head subluxation (3)
* Reduction via **supination-flexion or hyperpronation**
* Make sure to premedicate with tylenol or motrin
* You can try 3-4 times, but less likely to succeed if its been 1+ day since injury
| You want to reduce it IMMEDIATELY
47
Describe the supination-flexion reduction technique.
| Radial head subluxation
1. Hold elbow with thumb over radial head
2. Quickly supinate forearm completely
3. Quickly flex forearm
48
Describe the hyperpronation technique (3)
1. Hold elbow with your thumb over the radial head
2. Hyperpronate forearm
3. Completely extend and then flex the forearm.
| EBM prefers this for the first attempt.
49
If reduction fails for a radial head subluxation, what do we do? (2)
1. Order XRs
2. Splint (posterior long-arm) and refer
50
If reduction succeeds for a radial head subluxation, what do we do? (3)
1. Tylenol/motrin PRN
2. +/- sling
3. Parent education
51
What tendinosis is MC: Lateral wrist (extensors) or Medial wrist (flexors)?
Lateral epicondylitis, aka **tennis elbow**
| Medial is golfer's elbow
52
What is the usual MOI for epicondylitis?
Chronic repetitive overuse
53
When is epicondylitis MC? (age range)
30-50
54
What causes pain in lateral epicondylitis? (2)
* Wrist extension
* Gripping (shaking hands, computer mouse, screwdriver, back-handed tennis swing)
| Extension and supination
55
Where does point tenderness occur in epicondylitis?
1 cm distal to the epicondyle
| Medial is the same.
56
What causes pain in medial epicondylitis? (2)
* Pronation and wrist flexion (golf, overhead throw, bowling)
* Gripping weakness
57
Dx of epicondylitis
Clinically
58
Managment of epicondylitis (5)
* Activity modification
* NSAIDs + Ice
* PT if failure of conservative tx
* **Counterforce brace**
* Steroids x 3 max
59
When should you refer to ortho regarding epicondylitis?
**Symptoms persists for 6 months** despite conservatie therapy
60
MOIs for olecranon bursitis (3)
* Trauma: fall, direct blow
* Inflammation: excessive leaning, RA, gout
* Infection: Septic bursitis MC d/t staph or strep
61
Presentation of chronic olecranon bursitis (2)
* Gradual swelling of bursa up to 6cm
* +/- pain, mild tenderness, limited ROM
62
Presentation of acute olecranon bursitis
* Sudden swelling of bursa
* Pain/tenderness/limited ROM
* **Redness and warmth**
63
When is aspiration indicated for olecranon bursitis? (1)
Large & Symptomatic
| Analyze fluid with CBC, gram stain, C&S, and for crystals
64
When is AP and lateral XR indicated for olecranon bursitis? (1)
Hx of trauma
65
Tx of non-septic olecranon bursitis with mild swelling (2)
* Activity modification
* NSAIDs
66
Tx of non-septic, large edematous olecranon bursitis (5)
* Aspirate
* Compression bandage
* f/u in 2-7 days
* Negative culture = reaspirate and reculture
* Negative culture x 2 with persistent swelling = aspirate + 1 mL corticosteroid
67
ABX for immunocompetent patient with mild, septic bursitis
Bactrim PO
| Alt: keflex
68
What is considered a severe septic bursitis?
* Systemic toxicity
* Rapid progression in 48hrs
* Unable to tolerate PO
* Close indwelling medical device
* **Immunosuppressed**
69
ABX for severe septic bursitis (2)
* **IV Vancomycin**
* Add cipro or zosyn if hx of trauma
| Need pseudomonal coverage for trauma
70
What is in a forearm XR series?
1. AP
2. Lateral
71
What is in a wrist/hand/finger XR series? (3)
1. PA
2. Oblique
3. Lateral
72
What is a Galeazzi fx? (2)
* Radial midshaft fx
* Unstable distal radioulnar joint (DRUJ)
73
What is a monteggia fx? (3)
* Promixal 1/3 ulnar shaft
* Dislocation of radial head
* Unstable proximal radioulnar joint (PRUJ)
74
MUGGER Mnemonic
* MU = monteggi**a** ulnar (A is proximal)
* GR = Galea**zz**i radial (Z is distal)
75
How does a forearm fx present? (3)
1. Deformtity, swelling, ecchymosis
2. Point tenderness overlying fx
3. Decreased ROM above and below
| Make sure to check NV status + **compartments**
76
What two indications require Emergent referral for ortho for a forearm fx?
1. Arterial compromise
2. Open fx
77
What 4 indications recommend an urgent referral to ortho for a forearm fx?
1. Ulnar fx with < 50% apposition or > 10d angulation
2. Any DRUJ or PRUJ instability
3. Peripheral nerve injury
4. Both bones got fx + displaced
78
What 3 indications are just priority referrals to ortho for a forearm fx?
1. Isolated radial fx
2. Both bones fx, but minimal/no displacement
3. Isolated proximal 1/3 ulnar fx
79
What is considered a simple, isolated fx of the ulnar shaft? (4)
* Middle-distal 1/3
* < 50% displacement
* < 10d angulation
* No joint involvement
80
How do we manage a simple isolated, non-proximal fx of the ulnar shaft?
1. Long-arm posterior splint with neutral forearm + slight wrist extension + 90d elbow
2. After 1-3 wks, change to a functional forearm brace for 4-6 wks
3. F/u Xrays at 1 week and q4wks until healing is done.
| Usually 8 weeks to heal.
81
When do we do a double sugar tong splint for a forearm fx?
1. Isolated radial fx
2. Combined radial + ulnar fx
3. Galeazzi or Monteggia fx
82
Carpal bones mnemonic
* Some (scaphoid)
* Lovers (Lunate)
* Try (**Tri**quetrum)
* Position (pisiform)
* That (Trapez**i**um)
* They (Trapez**o**id)
* Cant (Capitate)
* Handle (Hamate)
| i before o
83
Nerve distribution of the hand (3)
* Ulnar: Medial (medial half of 4th digit + pinky)
* Median: Palmar Lateral (Lateral half of 4th digit to thumb)
* Radial: Dorsal Lateral hand (Thumb + 2nd and 3rd digit up to PIP joint)
84
Palmar vs Dorsal Blood flow
* Palmar has two arches and is fed by both ulnar and radial arteries
* Dorsal has 1 arch and **is fed solely by radial artery**
85
MC MOI for a wrist fx?
FOOSH
86
MC type of wrist fx between Colles and Smith
Colles fx: distal radial fx is tilted dorsally
| Dinner fork deformity (collard greens for dinner)
87
Describe a smith's fx
Distal radial fragment tilted volarly/palmarly
| Garden **spade** deformity
88
How does a wrist fx present clinically? (3)
* Acute pain
* Tenderness
* Swelling
89
Colles Fx XR
90
Smith Fx XR
91
Management of a non/minimally displaced non-articular wrist fx
* Sugar tong or short arm cast for 2-3 weeks (but wait 72hrs to allow swelling)
* AP and lateral XR weekly for 2 weeks
| Wrist fx swell a lot!
92
Management for displaced or open wrist fx?
ORIF
93
What is the MC type of carpal bone fx?
Scaphoid
| in young men ):
94
What are the 3 main complications of untreated scaphoid fx?
1. High incidence of a delayed dx
2. Non-union
3. Avascular necrosis
95
What is the MOI for a scaphoid fx?
FOOSH onto hyperextended hand.
96
What 3 things are seen on clinical presentation of a scaphoid fx?
1. Wrist pain/swelling along **radial aspect**
2. **Tenderness along anatomical snuff box**
3. Grip/ROM is painful/limited/weak
97
What XRs do you order for a scaphoid fx? (2)
* Wrist series
* Scaphoid/navicular view (PA with wrist ulnar deviated)
| CT/MRI if neg but suspicious still.
98
Management of a nondisplaced fx/negative XRAY scaphoid fx (4)
* Thumb spica splint/cast x 6 wk
* Refer to ortho
* Repeat XR in 1-2 weeks if it was initially negative
* If XR is negative AGAIN but still tender, CT/MRI.
99
Management for a displaced scaphoid fx (2)
* ORIF
* Percutaneous pin placement
100
What nerve is compressed in carpal tunnel syndrome? (CTS)
Median nerve
101
What 4 physical tests are used to evaluate CTS?
1. Tinel's
2. Phalen's
3. Carpal compression test
4. Hand elevation test
102
What physical sign suggest late CTS?
Thenar atrophy
103
Besides activity, what can aggravate CTS?
Nighttime
104
To diagnose CTS, what must be done?
EMG/NCS
105
What are the primary management options for CTS? (3)
1. Activity modification
2. Cock-up wrist splint
3. Corticosteroid injections
106
When do you refer to ortho for CTS release? (2)
1. **Failure of 3 months** of conservative therapy
2. **Objective neuro findings/thenar atrophy**
107
What is the MC hand fx?
Boxer's fx = fx of 4th +/- 5th metacarpal
108
In children, which part of the 5th phalange is typically injured?
physis of the 5th phalange
109
In adults, which part of the 5th phalange is MC injured?
Distal phalanx
110
How do Boxer's fx tend to appear?
Malrotated
| Note the pinky rotation
111
For a metacarpal neck fx, when can you reduce it vs splint it?
* > 30deg angulation => reduce it
* < 30deg angulation = splint for 2-3 weeks
112
What metacarpal neck fx requires an ulnar gutter splint? Radial gutter splint?
* Ulnar gutter = 4th or 5th metacarpal
* Radial gutter = 2nd and 3rd metacarpal
113
For a non-displaced fx of 2-5th metacarpal/phalangeal shafts, what is the management? (2)
* Metacarpals: Gutter splints for 3-4 weeks
* Phalangeal: Buddy tape/aluminum splint
114
For a non-displaced fx of the 1st metacarpal/phalange, what is the splint?
Thumb-spica + wrist in 30deg extension
115
For a non-displaced/non-articular fx of the 1st metacarpal **base**, what is the management?
Thumb spica splint/cast x 4 weeks
116
For any displaced/angulated metacarpal/phalangeal shaft fx or intra-articular fx, what do you do for management?
Call Ortho :)
117
What causes gamekeeper's thumb and what occurs?
| Also called skier's thumb
* MOI: Forced radial abduction
* Rupture of UCL of 1st MCP joint
118
Clinical presentation of gamekeeper's thumb (3)
1. Pain/swelling/tenderness along **medial 1st MCP joint**
2. Weak pincer function
3. Stress test after local anesthesia
119
Management for gamekeeper's thumb (2)
* Thumb spica splint
* Refer to Ortho
120
Cause and pathology of mallet finger (2)
* MOI: Hyperflexion of DIP
* Pathology: Rupture/lac/avulsion of **extensor tendon at distal phalanx**
121
Clinical presentation of Mallet finger (4)
1. DIP flexed at around 40deg + **inability to actively extend**
2. **PROM is intact**
3. Mild tenderness over dorsal DIP
4. May be associated with avulsion fx
122
Managment of mallet finger (2)
* Splint of **DIP in full extension** for 4-8 wks
* **CANNOT REMOVE SPLINT**
123
What will occur with an improperly treated mallet finger?
Swan neck deformity
124
Cause and pathology of boutonniere deformity (2)
* MOI: forced flexion of **PIP**
* Pathology: Rupture of central extensor tendon on middle insertion
| The PIP version of mallet finger
125
How does Boutonniere deformity present? (4)
* Finger partially flexed at PIP but extended at DIP
* Swelling/pain/point tenderness along dorsal PIP
* Limited ROM
* **Inability to fully extend PIP**
126
Management of Boutonniere deformity
Splint **PIP in extension but leave DIP free for 4-8 weeks**
| A more proximal version of mallet finger splinting
127
When do you refer to ortho for boutonniere deformity? (3)
* Failed conservative
* **Associated irreducible PIP dislocation**
* Open fx
128
Describe the pathology of De Quervain's tenosynovitis
Inflammation of **tendon sheath covering extensors and ABductors of the thumb**
129
Clinical presentation of De Quervain's Tenosynovitis (3)
* Aching pain/point tenderness along radial wrist
* Pain can radiate up arm
* Thickened 1st dorsal compartment
130
What physical test is diagnostic of De Quervain's tenosynovitis?
Finkelstein test
| Ulnar deviation of adducted thumb = pain, not sure if its rlly diagnostic
131
Management of De Quervain's tenosynovitis (3)
* Thumb spica splint
* Modify activity
* NSAIDs
132
What 2 things can ortho do for De Quervain's?
1. Corticosteroid injections into tendon sheath
2. Surgical release of 1st dorsal compartment
133
What do ganglion cysts overly?
Joints or tendon sheaths
134
MC location and age for a ganglion cyst?
Female 10-40 over their dorsal aspect of wrist
| Also called bible cyst so you smack it with your bible
135
How can you differentiate a ganglion cyst from a solid lesion?
Transillumination
| Clinical dx
136
Management of a ganglion cyst (3)
1. Observe it until it regresses
2. Aspiration +/- corticosteroid
3. Surgical removal
137
What is the underlying pathology of trigger finger? (2)
1. Idiopathic dysfunction of flexor tendon as it glides through sheath
2. **Usually due to tendon size and sheath discrepancy**
138
MC digits affected with trigger finger? (2)
* 3rd
* 4th
139
How does trigger finger present? (4)
* Catching/snapping/locking of finger
* **Worse at night**
* Painful nodule on palm
140
Management of Trigger Finger (3)
* NSAIDs
* Corticosteroid injection (**1 max if hx of RA**, otherwise 2nd in 3-4 wk)
* Surgical release if above fails
141
What is Dupuytren's contracture and who is it MC in?
* Progressive fibrosis of palmar fascia
* MC in **men older than 50.**
142
RFs for Dupuytren's (6)
* Epilepsy
* DM
* Pulmonary disease
* ETOH
* Smoking
* Repetitive vibrational trauma (like a jackhammer)
143
MC phalange affected in Dupuytren's
4th
144
How does Dupuytren's contracture present?
* Painless nodules near distal palmar crease
* Cord that contracts as nodules thickens
* **Limited extension**, normal flexion
145
Management of Dupuytren's (2)
* Night splinting at night to help slow progression
* Surgical **release indicated if MCP is flexed more than 30deg**
146
3 MOIs that can cause brachial plexus syndrome
1. Traction force
2. Direct blow to top of shoulder
3. Stretching of plexus during arm ABduction (grabbing when falling)
147
What are the **primary nerves** that make up the brachial plexus?
C5-T1
148
Which MOIs for brachial plexus syndrome cause C5-C7 damage typically?
* Traction force
* Direct blow
149
Classic symptoms seen in brachial plexus syndrome (2)
* **Sharp, burning pain with radiculopathy in affected nerve root distribution**
* Weakness
150
Injuries to what part of the brachial plexus may also cause Horner's syndrome?
C8-T1
| PAM (ptosis, andhidrosis, miosis)
151
What physical finding might suggest the spinal cord is injured instead of just the brachial plexus?
Ipsilateral leg spasticity or weakness
152
Image of C-spine nerve root physical tests
153
When is MRI indicated in diagnosinsg brachial plexus syndrome? (2)
* Abnormal XRs
* Persistent symptoms
154
What test might help us pinpoint specific locations of nerve dysfunction?
EMG/NCS
155
Management of Brachial plexus syndrome (3)
* Strengthening and stretching
* Splinting neutral position if any joints are affected by paralyzed muscles
* **Encourage PROM**
| Atheletes cannot return to activity until fully resolved.
156
What is in the thoracic outlet? (5)
* First rib
* Subclavian artery/vein
* Brachial plexus
* Clavicle
* Lung apex
157
What is thoracic outlet syndrome and who is it MC in?
* Compression of brachial plexus and/or subclavian vessels in shoulder girdle/1st rib
* MC in women 20-50
158
How does thoracic outlet syndrome present?
1. Compression of brachial plexus
2. Compression of vascular structures (swelling/discoloration)
3. Fatigue, weakness, aching pain
4. **Exacerbated by lifting arm above head**
159
What must you palpate for if you suspect thoracic outlet syndrome?
Supraclavicular fossa to assess for a mass
160
What is the physical test used to check for thoracic outlet syndrome?
Elevated arm stress test
161
Management of Thoracic outlet syndrome (3)
* Home exercise programs
* Muscle strengthening + posture exercises
* NSAIDs, muscle relaxers, TENS
