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MSK/Rheum Exam- Clin Med > Ortho- Upper > Flashcards

Ortho- Upper Flashcards

1
Q

Normal elbow rom degrees

A

Flexion 140
Extension 0
Pronation and supination 90

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2
Q

Normal wrist ROM degrees

A

Extension and flexion 90

Ulnar and radial deviation 30

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3
Q

Manual muscle grading

A 
5/5 complete ROM against max resistance 
4/5 complete ROM w moderate resistance 
3/5 against gravity 
2/5 complete ROM w gravity removed 
1/5 no ROM, isometric muscle contraxn
0/5 no muscle contraction
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4
Q

Can have impingement of….

A

Subacromial bursa
Rotator cuff
(Compressed between humeral head and acromion)

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5
Q

Epidemiology of impingement/bursitis/tendonitis

A

Middle aged adults
Atraumatic onset
Repetitive overhead work
Gradual progression

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6
Q

Impingement symptoms

A 
Pain w overhead reaching, lifting 
Night pain
Ache 
Catching at about 80-120 degrees, painful arc
No acute onset
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7
Q

Generalized tenderness, rarely point tender
Possible slight decrease in AROM
Full PROM
Manual muscle testing normal (possible slight decrease secondary to pain)

A

Impingement

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8
Q

Pos impingement sign

Pos Hawkins maneuver

A

Impingement

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9
Q

Impingement diagnostics

A

Physical exam

X Rays- a/p, axillary lateral (may show subacromial spur)

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10
Q

Impingement treatment

A

Relative rest…eliminate aggravating factors
NSAIDS
Cortisone injection
Physical therapy…RC strengthening
Surgery..arthroscopic subacromial decompression

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11
Q

4 muscles of rotator cuff

A

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

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12
Q

Rotator cuff tear

A

Complete or partial disruption of musculotendonous complex

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13
Q

Seen in older adults, rarely younger than 30
Rarely traumatic
May result from prolonged impingement

A

Rotator cuff tear

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14
Q

May or may not have specific MOI
Pain or weakness w elevation/rotation
Progressive in nature
Pain at night

A

Rotator cuff tear

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15
Q

Possible muscle atrophy, tenderness w palpation, crepitus w PROM
Decreased AROM
Pain w AROM (elevation, ext rotation)
Minimal pain w PROM
Weakness and pain w manual muscle testing

A

Torn rotator cuff physical exam

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16
Q

Special tests with torn rotator cuff

A 
Impingement sign
Hawkins maneuver 
Drop arm tst 
Empty can test
Lift off test
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17
Q

X Rays with rotator cuff tear

A

May show subacromial spur

May show calcific tendonosis

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18
Q

MRI with rotator cuff tear

A

Definitive but not 100%

Expensive!!

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19
Q

Conservative rotator cuff tx

A

PT
cortisone injections
NSAIDs

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20
Q

Surgery w rotator cuff tear

A

Arthroscopic or open repair of RC

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21
Q

Possible consequences of RC tears

A

RC arthritis and or arthropathy

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22
Q

Normal shoulder ROM degrees

A 
Forward flexion 180
Abduction 180
Adduction 60
Extension 60
Internal and external rotation 90
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23
Q

Shoulder separation

A

Acromioclavicular stress or disruption

May involve other structures

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24
Q

Can occur at any age, but usually young adults to middle aged
History of specific trauma..fall on “point of shoulder”

A

Shoulder separation

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25
Q 
Sudden onset of pain after trauma 
Felt pop or crunch in shoulder 
Pain w or without motion 
Decreased ROM
Arm "went dead"
A

Shoulder separation

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26
Q

Can have obvious deformity depending on grade
Depressed affected shoulder
Unwillingness to move arm
Decreased AROM and PROM secondary to pain

A

Shoulder separation

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27
Q

Shoulder separation special tests

A

Cross arm test
Pain w horizontal abduction
Spring test

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28
Q

X ray of shoulder separation

A

A/P

Possible bilateral

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29
Q

Conservative shoulder separation tx

A

For grades 1-3
Immobilization in sling for 1-3 weeks then PT
Rest
NSAIDs

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30
Q

Surgical tx for shoulder separation

A

For grades 3-6

Needed if unstable or cosmetic

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31
Q

Degenerative arthritis of AC joint
Usually in middle aged men
Manual laborers, weight lifters, athletes
May have initial traumatic event

A

AC degenerative joint disease

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32
Q

Rarely known moi
Pain at AC joint
Pain w pushing, horizontal adduction
Pain laying on shoulder

A

AC DJD

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33
Q 
May have AC hypertrophy
Tenderness at AC joint 
May have crepitus
Normal AROM and PROM
MMT normal
A

AC DJD

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34
Q

Special test for AC DJD

A

Cross arm test

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35
Q

X Ray with AC DJD

A

A/P and axillary lateral

Will show evidence of degenerative changes

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36
Q

Conservative tx of AC DJD

A

Rest
NSAIDs
Cortisone injection

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37
Q

Surgical tx of AC DJD

A

Excision of distal clavicle (Mumford procedure)

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38
Q

Clavicle fracture

A

Very common among active
Usually between middle and lateral third of clavicle
Great variability in size, deformity

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39
Q

History of trauma
Pt feels crepitus at fx site
Pain w AROM/PROM and at rest

A

Clavicle fracture

..pt often knows and will tell you “I broke my collar bone”

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40
Q

Clavicle fracture physical exam findings

A 
Obvious deformity
Pain over fx site on palpation
Possible crepitus w palpation 
Pain with AROM and PROM
MMT intact but painful
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41
Q

X Rays in clavicle fracture

A

A/P
Usually easily seen
Bone fragments usually overlap

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42
Q

Treatment of clavicle fx

A

Conservative…sling 3-4 weeks
Gradual return to rom, activity

…if unstable, surgery may be required

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43
Q

Generalized laxity of glenohumeral joint
Dislocation..full disarticulation of GH joint
Subluxation..partial disarticulation

A

Shoulder instability

44
Q

Most common in younger patients..overhead athletes
Can be Traumatic (95% are anterior dislocations)
90% will reoccur
Can be atraumatic..”voluntary dislocators”

A

Shoulder instability

45
Q 
Usually traumatic event 
May or may not relocate spontaneously 
Dead arm
Pain and apprehension w ROM
Sense of instability 
May sense clicking in GH joint
A

Shoulder instability

46
Q 
PE reveals...
Flattened deltoid
Prominent acromion 
Pain
Arm held in splinted position
Dramatically reduced AROM/PROM
A

Shoulder dislocation

47
Q 
PE shows...
Normal shoulder appearance
Non tender palpation 
Near full ROM
MMT normal
A

If shoulder dislocation has been reduced

48
Q 
Anterior/posterior humeral drawer
Sulcus sign (inferior instability)
Anterior apprehension w passive ext rotation
Relocation test
Ant/post load and shift test
Active compression test (labral tear)
A

Special tests for shoulder dislocation

49
Q

X Ray for shoulder instability/dislocation

A

A/P, axillary lateral, Y view
**always X-ray first time dislocators!!!!
Always x ray post reduction
Must suspect fx and or Hill-Sach lesion

50
Q

Best diagnostic way to assess in Bankart lesion in shoulder dislocation

A

MRI

51
Q

Conservative tx for shoulder instability

A

Modify activity
Physical therapy-RC strengthening
NSAIDs

52
Q

Surgical tx for shoulder instability

A

Bankart (labral) tear

Capsulorrhaphy

53
Q

Frozen shoulder
Insidious onset
Unknown cause..probably inflammatory
Most common among middle aged women

A

Adhesive capsulitis

54
Q 
No known injury or onset
Gradual progression 
Gradually limited ROM
Pain at limits of motion
Pain at night
A

Adhesive capsulitis

55
Q 
PE shows..
Normal appearance
Minimal tenderness on palpation
Decreased PROM/AROM 
Pain at limits of motion
MMT normal
A

Adhesive capsulitis

56
Q

Diagnosis of adhesive capsulitis made by…

A

History and physical exam

Take x ray to rule out other bony pathology

57
Q

Adhesive capsulitis treatment

A 
Physical therapy 
NSAIDs
Cortisone injection
Manipulation under anesthesia 
**may take over a year to resolve!!!**
58
Q

Most common dislocation in children
50% are result of sports
Fall on out stretched hand is MOI
Most (98%) are posterior

A

Elbow dislocation

59
Q

Traumatic event
Arm held at side in splints position
Immediate pain
Inability or unwillingness to move elbow

A

Elbow dislocation

60
Q 
PE shows...
Obvious deformity..prominent olecranon
Swelling
Pain w palpation
Decreased AROM
A

Elbow dislocation

**MUST ASSESS NEUROVASCULAR STRUCTURES WITH AN ELBOW DISLOCATION

61
Q

X ray with elbow dislocation

A

Not initially necessary
Must perform post reduction
*high incidence of associated injury or fx

62
Q

Elbow dislocation tx

A

Reduction
Splint/cast for 1-3 weeks
Initiate early ROM exercise to reduce chance of flexion contracture
NSAIDs

63
Q

“tennis elbow”
Inflammation or degeneration of wrist extensors
Usually in middle aged adults
Overuse injury (golf, tennis, construction workers)

A

Lateral epicondylitis

64
Q

Gradual onset, no MOI
Pain w repetitive wrist flexion/extension
Possible localIzed swelling
Pain may radiate down forearm

A

Lateral epicondylitis

65
Q 
PE shows..
Normal inspection of elbow
Point tenderness at lateral epicondyle
Normal ROM
Pain w passive wrist flexion
Pain w active wrist extension
A

Lateral epicondylitis

66
Q

Lateral epicondylitis treatment

A 
Eliminate aggravating factors 
NSAIDs 
Ice and heat
PT
Tennis elbow strap
Cortisone injection
Surgical release/fasciotomy
67
Q

Inflammation of olecranon bursa
Usually precipitated by traumatic event
Any age

A

Olecranon bursitis

68
Q 
Quick onset 
May have known MOI 
Pain w pressure on elbow
Variable swelling 
Tightness with ROM
May have fever, erythema if infected
A

Olecranon bursitis

69
Q

Obvious olecranon swelling
May have erythema and intense pain on palpation (suspect infection!)
May not be tender on palpation if chronic
Slight decrease in ROM
Strength in tact

A

Olecranon bursitis

70
Q

Treatment in olecranon bursitis

A 
Aspirate fluid! (Send for analysis..culture, crystals)
Compression wrap/padding
NSAIDs
Heat and or ice
Cortisone injection
71
Q

If olecranon bursitis is infectious…

A

Treat cultured pathogens

Incision, drainage and packing

72
Q

Entrapment of median nerve under transverse carpal ligament
Most common nerve entrapment syndrome
May result from inflammation, fluid retention, trauma, overuse

A

Carpal tunnel syndrome

73
Q 
No known MOI
Pain w typical static ADLs
Pain and numbness into median distribution 
Night pain is common
Weakness of thumb, grip strength
A

Carpal tunnel

74
Q 
PE shows...
Thenar atrophy
Tenderness at palmar wrist area 
ROM normal 
Decreased thumb opposition strength
Decreased/abnormal sensation in median distribution
A

Carpal tunnel

75
Q

Special tests for carpal tunnel

A

Phalens test
Tinels sign
Decreased 2 pt discrimination

76
Q

Diagnostics in carpal tunnel

A

Nerve conduction studies

77
Q

Carpal tunnel conservative treatment

A

Night splints
NSAIDs
Activity modification
Cortisone injection

78
Q

Carpal tunnel surgical treatment

A

Release of transverse carpal ligament

79
Q

Inflammation of tendon sheath (synovium) surrounding tendons of thumb (tenosynovitis)

A

DeQuervians disease

80
Q

Which muscles/ tendons involved in DeQuervains disease

A

Extensor pollicus brevis

Abductor pollicus longus

81
Q

Pain with repetitive motion of thumb
Possible swelling
Stiffness
Weakness

A

DeQuervain disease

82
Q 
PE shows...
Possible swelling
Point tender over tendons at CMC joint
Pain w resisted thumb opposition
Pain w thumb flexion
A

DeQuervain

83
Q

Special test for DeQuervain disease

A

Finkelstein

84
Q

Diagnostics for DeQuervains disease

A

X ray to rule out bony pathology like OA

Labs if diagnosis is in doubt (?gout)

85
Q

DeQuervain conservative tx

A

NSAIDs
Splint
Cortisone injection
*symptoms usually resolve by 1 year

86
Q

Surgical treatment for DeQuervain

A

Fasciotomy of 1st dorsal compartment

87
Q 
Most commonly fractured carpal bone
Blood enters distal third of bone 
High rate of non unions (50-90%)
20-40 year old men most common
Rare in children
A

Scaphoid fracture

88
Q

MOI falling on out stretched hand
Pain at base of thumb and or wrist
Pain w rom and gripping

A

Scaphoid fx

89
Q 
PE shows...
Possible swelling
Pain w palpation of snuffbox 
Decreased rom due to pain
Pain with MMT
A

Scaphoid fx

90
Q

X-rays w scaphoid fx

A

Scaphoid views (ulnar deviation and oblique)
Most likely negative initially!!
**must repeat X-ray 2 weeks post injury
Look for fx or signs of healing

91
Q

Bone scan with scaphoid fx

A

Shows evidence of generalized metabolic activity

92
Q

Tx of scaphoid fx

A

Cast at least 2 weeks (even if no fx seen initially)
Total cast time can be up to 12 weeks
Re X-ray at 2 weeks to assess healing

93
Q

If scaphoid fx is healing at 2 week X-ray….

A

Recast for at least another 4 weeks

94
Q

If X-ray after 2 weeks of scaphoid shows no fx…

A

Splint for 2 weeks

95
Q

If X-ray after 2 weeks after scaphoid fx shows displacement..

A

Refer to surgeon

96
Q

Rupture of extensor tendon at distal phalynx

Most common extensor injury

A

Mallet finger

97
Q

Hyper flexion injury
Pain and swelling at distal fingertip
Inability to extend fingertip

A

Mallet finger

98
Q 
PE shows...
Swelling and ecchymosis at DIP
pain on palpation 
DIP at slight flexion 
Cannot actively extend DIP
A

Mallet finger

99
Q

Mallet finger tx

A

Splint DIP in full extension
Wear splint for 4 weeks
Initiate gentle ROM after splint removed

100
Q

Rupture of flexor digitorum profundus

A

Jersey finger

101
Q

Known moi
Pain and swelling at distal finger
Inability to flex fingertip

A

Jersey finger

102
Q

PE shows..
Swelling and ecchymosis at dip
Pain at DIP joint
Unable to actively flex DIP

A

Jersey finger

103
Q

Jersey finger treatment

A

Initially splint finger in flexed position
Refer for surgical eval
all flexor tendon injuries require surgical repair**

104
Q

Tear of the central slip (median band) of extensor tendon at PIP level
PIP flexes due to unopposed action of FDS
DIP joint extend due to pull of intact lateral bands

A

Boutonnière deformity

105
Q

Hx of trauma
Inability to extend PIP joint
Pain w any active motion

A

Boutonnière deformity

106
Q

PE shows…
Pain and swelling at pip joint
Inability to actively extend PIP

A

Boutonnière deformity

107
Q

Boutonnière treatment

A

Splint PIP joint in extension
May leave DIP joint free for motion to avoid stiffness
Splint for at least 6 weeks
Gradually initiate ROM exercises after splint removed

MSK/Rheum Exam- Clin Med (7 decks)

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