UE Disorders

Question 1

3 bones that make up the shoulder?

Answer 1

• Humerus
  
  • Clavicle
  • Scapula

Question 2

4 Articulations of the shoulder?

Answer 2

1. Glenohumeral (GH)
   
   • ball & socket joint
   • bulk of the motion occurs here
   • 2/3 of the shoulder motion comes from GH joint
2. Scapulothoracic
   
   • elevates the arm
   • 1/3 of the shoulder motion comes from this
3. Acromioclavicular Joint (AC joint)
   
   • articulation of the acromion process & distal clavicle
   • little or no motion
4. Sternoclavicular Joint (SC joint)
   
   • proximal clavicle articulates with sternum
   • little or no motion

Question 3

Rotator Cuff Muscles and Functions?

Answer 3

Rotator cuff muscles make up the intrinsic muscles of the shoulder
Tendons come together & form a common tendon that is important in shoulder stability
Supraspinatus is the most superior muscle & most susceptible to injury
Subscapularis is the anterior muscle of the cuff & acts as an internal rotator 
Infraspinatus is a posterior muscle & acts as an external rotator
Teres Minor (posterior) & acts as external rotators

Question 4

Extrinsic Muscles of the Shoulder include?

Answer 4

• Deltoid
  
  • Pectoralis major
  • Latissimus dorsi
  • Teres major
    Function to move the humerus

Question 5

Bicep muscle function

Answer 5

Acts as both an intrinsic & extrinsic muscle
Intrinsic function is to stabilize the GH joint
Extrinsic function flexes the elbow
Important in throwing & overhead motion

Question 6

Patients < 40 y/o with glenohumeral instability are more likely due to?

Answer 6

to labral injuries (dislocations & SLAP tears), chondral injuries, AC separation, stress fx, & fx secondary to high energy impact & trauma

Question 7

Patients > 40 y/o with glenohumeral instability are more likely due to

Answer 7

calcific tendinitis, fractures, AC & GH osteoarthritis, frozen shoulder, rotator cuff tendinitis, impingement, & rotator cuff tear

Question 8

Focal pain on top of the shoulder suggests what?

Answer 8

AC joint involvement

Question 9

5 Peripheral nerves that can be injured and affect shoulder function

Answer 9

Axillary Nerve (C5-6)
Suprascapular Nerve (C5-6)
Musculocutaneous Nerve (C5-6)
Long Thoracic Nerve (C5-8)
Spinal Accessory Nerve

Question 10

Axillary nerve affects what?

Answer 10

Most commonly injured
Occurs most commonly with anterior dislocation
Can also be injured with brachial plexus injury or compression or during shoulder surgery
Affects deltoid function
- weakness results in inability to abduct
Affects Teres minor function
- weakness results in decreased external rotation, but
can be compensated for & not easily recognized
Sensory loss over the deltoid most profound in a 2-3 cm area over the deltoid insertion
No DTR’s are affected

Question 11

Suprascapular nerve injury?

Answer 11

Can be injured with a fall on the posterior shoulder, stretch injury, or fractured scapula
Signs & symptoms mimic rotator cuff injury
History & mechanism of injury are important in distinguishing between the two
Seen in patients who do overhead throwing
Presents with posterior shoulder pain, weakness in shoulder abduction & external rotation
No DTR’s are affected

Question 12

Musculocutaneous Nerve injury

Answer 12

Rarely injured
Usually from direct trauma with a humeral fx or along with a brachial plexus injury
Weakness in biceps & brachialis muscles resulting in weakness of elbow flexion
Sensory alteration on lateral aspect (thumb side) of the forearm
Biceps DTR is affected

Question 13

Long Thoracic Nerve Injury?

Answer 13

Not very common
Usually occurs from repetitive microtrauma with heavy effort above shoulder height (shoveling, chopping, carrying a heavy backpack)
Weakness of the serratus anterior can result in scapular winging & difficulty with abduction > 90 degrees
No associated sensory or DTR abnormalities

Question 14

Spinal Accessory Nerve Injury

Answer 14

Usually injured in the neck
Often injured due to poorly fitting backpack
Injury occurs distal to the cranial nerve & a portion of the sternoclidomastoid muscle is not affected
Trapezius muscle is affected
Shoulder shrug is diminished on the affected side
Difficulty with abduction > 90 degrees
No significant sensory disturbance except shoulder is aching
No DTR abnormalities

Question 15

Rotator Cuff Tendonitis

Answer 15

Common complaint
Can occur at any age especially in those engaged in overhead activities
Results in edema & inflammation in the rotator cuff & sometimes micro tears
Thickening of the tendon with inflammation of overlying bursa

Question 16

Clinical Presentation of Rotator Cuff Tendonitis

Answer 16

Pain in the shoulder radiates to the upper arm, but not past the elbow
Pain is worse with overhead activity including putting on a shirt & brushing hair
Pain may be localized to lateral deltoid area
Pain may be worse at night when lying on the affected shoulder

Question 17

Treatment of Rotator Cuff Tendonitis

Answer 17

Rest – avoid all provocative activities
Sling is not encouraged as it may cause more stiffness
Gentle ROM may be advanced to PT if needed when tolerable
Ice
NSAID’s
Patients who do not respond may require steroid injection
Modifications to work or activity may be required to avoid chronic inflammation
Most improve in 4-6 weeks

Question 18

Calcific Tendonitis

Answer 18

Presentation is often similar to the patient with tendinitis, but patient often notes more pain with ROM
Physical exam is similar to tendinitis, but often more pain with ROM & more palpable tenderness
Xray demonstrates calcium deposit as an increased area of density overlying the supraspinatus

Question 19

Treatment of Calcific Tendonitis

Answer 19

Steroid injection is the treatment of choice
Calcific material often resorbs spontaneously
In severe cases subacromial decompression arthroscopic surgery & needling of the calcific deposit is required

Question 20

Impingement Syndrome

Answer 20

Most common cause of shoulder pain
Attributable to the compression of structures around the GH joint that occur with shoulder elevation
Usually refers to problems with any of 3 soft tissue structures of the subacaromial (SA) space including the SA bursa, biceps tendon (long head), & the rotator cuff
Risk factors include repetitive activity at or above shoulder level during work or activities, instability of the GH joint, & scapular instability

Question 21

Clinical Presentation of impingement syndrome

Answer 21

Similar to those with tendinitis including pain with overhead activity
The pain may localize to the deltoid area & often occurs while sleeping on the affected side
Throwing athletes c/o stiffness & pain in the posterior shoulder during the early acceleration or cocking phase
Serving athletes c/o pain with follow through or terminal wrist snap

Question 22

Diagnostic Imaging for impingement syndrome?

Answer 22

Xray in the initial phase is only indicated with a traumatic injury, but is usually done to R/O any type of fx
MRI is performed if the symptoms & function fail to improve with conservative treatment, the dx remains unclear after initial evaluation, or there is a suspected rotator cuff or labrum tear

Question 23

Stage 1 impingement syndrome

Answer 23

Stage 1

• edema & hemorrhage
• patients usually < 25 y/o

Question 24

stage 2 impingement syndrome

Answer 24

Stage 2

• fibrosis & tendinitis
• patients generally 25 – 40 y/o

Question 25

stage 3 impingement syndrome

Answer 25

Stage 3 - most common - rotator cuff tear - patients generally > 40 y/o - patients have usually had at least one ocurrence of Stage 1 or Stage 2

Question 26

Treatment for impingement syndrome

Answer 26

Initial management is similar to tendinitis including rest (avoid provocative movements), ice, & 7-10 day course of NSAID’s PT may also be included to regain strength & ROM Steroid injections may provide symptomatic relief & improve the patients effort & compliance with PT Surgical subacromial decompression is the definitive treatment as it opens the space & gives direct visualization to the rotator cuff

Question 27

Acute Traumatic Tears of Rotator Cuff

Answer 27

- result from a fall on an outstretched hand or by grabbing on while falling - pain is usually acute & referred to the deltoid - significant pain when sleeping on the affected side

Question 28

Degenerative Chronic Tears of Rotator cuff

Answer 28

similar to tendinitis & impingement syndrome | - wear on rotator cuff tendon gradually tears through

Question 29

Imaging for acute rotator cuff tears

Answer 29

Partial tears may heal themselves within 6 weeks, but if not improved by this point it probably will not heal & surgery may be indicated Xray is usually not helpful as it will not show the soft tissue structures MRI is the gold standard, but may need Gadolinium Shoulder arthrogram may be needed in patients with contraindications to MRI

Question 30

Treatment for Acute rotator cuff tears

Answer 30

Partial tears are treated like tendinitis & may resolve on its own, but sometimes require surgery Complete tears usually require surgery & are done either arthroscopically or as an open repair depending on how large the tear is Post-op patients require 2-4 weeks of restricted motion in a sling & then begin gentle ROM

Question 31

Degenerative Chronic Rotator Cuff tear imaging/ treatment

Answer 31

Usually seen in patients older than 40 y/o Similar symptoms as acute tear or impingement Xray can be helpful as it shows the loss of the normal subacromial space consistent with a chronic tear Will require surgical repair for definitive treatment Post-op care is the same

Question 32

Disorders of the LAbrum

Answer 32

SLAP tears occur when there is damage to the superior most aspect of the labrum SLAP – superior labral tear from anterior to posterior Symptoms are similar to rotator cuff tear, tendinitis, & impingement syndrome Patients will have weakness against resistance on the affected side with their palms up & arms extended from the body at 90 degrees on exam

Question 33

Treatments for D/O of the labrum

Answer 33

Definitive treatment of Bankart Lesions & SLAP tears is usually through arthroscopic surgical repair to correct the instability followed by 2-4 weeks of sling & swathe immobilization Rehab with PT to restore strength & ROM is necessary after surgery

Question 34

Bursitis

Answer 34

Symptoms similar to impingement syndrome Usually occurs in patients > 40 y/o Most often treated conservatively May lead to impingement if chronic

Question 35

What is a frozen shoulder? | Epidemiology of a frozen shoulder?

Answer 35

Defined by AAOS as a condition of varying severity characterized by the gradual development of global limitation of active & passive shoulder motion where radiographic findings other than osteopenia are absent Develops commonly after shoulder injury & extended immobilization Also referred to as adhesive capsulitis, however these patients will have more severe pain Occurs in 2-5% of the population Women > Men Most common > 40 y/o

Question 36

Risk factors for Frozen shoulder? | Pathophys for a frozen shoulder?

Answer 36

Risk factors include DM, thyroid disease, CVA, autoimmune diseases, Parkinsons Disease, & use of antiretroviral therapy Pathophysiological process involves thickening & contraction of the GH joint capsule & the collagenous tissue surrounding the joint thereby markedly reducing the joint volume

Question 37

Clinical Presentation of a frozen shoulder?

Answer 37

Initial painful phase with development of diffuse, severe, & disabling shoulder pain that is worse at night & increasing stiffness that lasts 2-9 months Intermediate phase with stiffness & severe loss of shoulder motion, but pain is gradually less pronounced that lasts for 4-12 months Recovery phase with a gradual return of ROM that takes from 5-24 months

Question 38

Treatment of a Frozen shoulder?

Answer 38

PT to restore motion usually not accomplished with a home exercise program Patients with true adhesive capsulitis will not benefit from PT until they are out of the inflammatory phase In some cases rupture of the adhesions with manipulation under anesthesia is necessary & is reserved for patients who do not respond to conservative treatment Intra-articular steroid injections have shown some benefit leading to improved ROM & pain reduction, however the effect is of limited duration & probably depends on the duration of the symptoms

Question 39

Bicep Tendinitis

Answer 39

Inflammation of the long head of the biceps tendon (& the tendon sheath in tenosynovitis) in the shoulder These patients present like rotator cuff tendinitis except that their inflammation is in the long head biceps tendon The long head biceps tendon is palpated in the bicipital groove of the anterior proximal humerus Pain is reproduced with the elbow flexed to 90 degrees & the forearm supinated against resistance (Yergason’s Test)

Question 40

Treatment of Bicep Tendinitis

Answer 40

Rest & activity modification Ice Gentle ROM Steroid injection into the tendon sheath if not improved with conservative treatment Most patients do respond with conservative treatment

Question 41

Bicep Tendon Rupture?

Answer 41

Occurs mostly in males > 50 y/o Many have a h/o chronic tendinitis Usually occurs as the result of heavy lifting or other explosive contraction of the biceps Patients note pain & a snapping sound/sensation Dx is easily made as biceps is retracted distally due to unopposed pull of the short head of the biceps tendon at the elbow Biceps is balled up looks like a “Popeye” muscle There is no conservative treatment as the injury is permanent & there will be some loss of strength Older patients tolerate the injury well Younger patients may require surgery, but this is a major procedure with a long period of inactivity followed by rehab

Question 42

Nonsurgical Treatment for Bicep Tendon Rupture?

Answer 42

Nonsurgical treatment may be considered for patients who are elderly and inactive, or who have medical problems that make them high-risk for modest surgery. Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible. The tendon should be repaired during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten. While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.

Question 43

Surgical Treatment for Bicep Tendon Rupture

Answer 43

Several procedures to reattach the distal biceps tendon to the forearm bone Some orthopedists prefer to use two incisions, while others only one incision Sometimes the tendon is attached with stitches through holes drilled in the bone Other times, small metal implants are used to attach the tendon to the bone.

Question 44

Osteoarthritis/DJD of the Shoulder What do you use for imaging? What is the Treatment?

Answer 44

Occurs when the cartilage wears out Shoulder motion diminishes gradually, but eventually becomes quite fixed & frozen Crepitus with motion is palpable Tolerated better than other types of OA as there is no weight bearing Xray shows collapse of joint space, osteophytes, deformity of humeral head Treatment is usually conservative In some cases patients will need arthroplasty or reverse shoulder replacement in those who also have a torn rotator cuff

Question 45

Osteolysis of Acromioclavicular Joint (ACJ DJD) What is the cause? What is used for imaging? What is the treatment?

Answer 45

Often seen in weight lifters Lysis (softening, absorption, & dissolution of bone) of the distal clavicle affects the AC joint Unlike other shoulder pain the patient will point at the AC joint when localizing the pain Lifting the arm impinges the AC joint & causes pain There is point tenderness to palpation at the AC joint Xray will demonstrate osteolysis of the distal clavicle Injection of lidocaine & steroid directly into the AC joint resolves the pain & is diagnostic The steroid may give relief for months, but pain usually reoccurs Definitive treatment is distal clavicle resection done open or arthroscopic

Question 46

3 main articulations in the elbow?

Answer 46

1. Humero-radial articulation formed by the radius & capitellum of the humerus 2. Humero-ulna articulation formed by the ulnar notch & the trochlea of the humerus 3. Superior radio-ulnar articulation formed by the proximal part of the radius & ulna

Question 47

Lateral Epicondylitis | What is used for Treatment

Answer 47

Commonly referred to as tennis elbow Overuse injury of conjoined tendons of extensor muscles in the forearm Pain over lateral epicondyle worse with movement & activity, dropping items, difficulty opening doorknobs & jars, & handshakes More common in dominant hand Tenderness to palpation over lateral epicondyle Pain worse with resistance against dorsiflexion of the wrist Treatment is conservative with rest, ice, NSAID’s, velcro wrist brace PT if resistant to conservative treatment Cortisone injection is sometimes helpful Surgery is uncommon but is usually definitive treatment in those who fail conservative treatment, PT, & Cortisone injections

Question 48

Medial Epicondylitis?

Answer 48

Commonly referred to as golfers elbow Medial equivalent of tennis elbow Pain is at medial epicondyle tendon of flexor muscles of the wrist Less common, but still an overuse syndrome Pain to palpation at medial epicondyle & pain with resisted palmar flexion of the wrist Treatment is the same as tennis elbow

Question 49

Olecranon Bursitis? | What is the treatment?

Answer 49

Relatively common Inflammation of the subcutaneous synovial lined sac of the bursa overlying the acromial process Because of the superficial position it is more susceptible to inflammation from acute or repetitive trauma Less commonly occurs from infection Exam reveals swollen, boggy, sometimes tender olecranon bursa Skin temp may be slightly increased Treatment is conservative with ice, NSAID’s, & compression with ace wrap for 7-10 days If conservative treatment fails aspiration & injection with a steroid should be considered

Question 50

What is Septic Olecranon Bursitis? What is the treatment? What is the MC bacteria?

Answer 50

Infected olecranon bursa Most common cause is disruption of the skin & bacteria enters Staph aureus/MRSA most common Exam reveals red, hot, swollen, tender olecranon bursa There may be pain with ROM & fever occasionally Treatment includes antibiotics with Staph/MRSA coverage including Keflex, Doxycycline, Trimethoprim Sulfamethoxazole If unresponsive to po antibiotics aspiration & C&S to identify pathogen & direct treatment towards it

Question 51

What is a Boutonniere Deformity? | What is the non surgical and surgical treatment?

Answer 51

Injury to the tendon that prevents full extension at the PIP joint MOI forceful blow to flexed finger or laceration Swelling pain & deformity at PIP joint Needs xray to determine if there is a fx Non-surgical treatment is splinting in full extension at the PIP joint for 6-8 weeks followed by hand therapy Surgical treatment is indicated if the deformity results from RA, tendon laceration, or displaced fx

Question 52

What is a Swan Neck Deformity? | What is the treatment

Answer 52

Hyperextended PIP & flexed DIP joints RA is the most common cause Non-surgical treatment requires hand therapy & splinting to restore the balance in the structures of the fingers for 6 weeks Not always effective Surgical repair can restore the balance of the structures around the PIP joint in joints that are not stiff In stiff joints surgical fusion is usually the choice

Question 53

What happens with Trigger Finder? MC Finger and at what age? Treatment?

Answer 53

Tendon on the flexor surface becomes thickened & nodules form at the A1 pulley Tendon becomes stuck & has to be pulled into extension Cause is unknown More common in women Usually ages 40-60 y/o more common More common in patients with DM & RA Most commonly occurs in the 4th finger but can occur in all fingers & the thumb Treatment can be conservative with rest & NSAID’s but is not always effective Steroid injections into the tendon sheath are usually more successful Surgery is a last option for those who fail conservative treatment & at least 2 steroid injections

Question 54

Dupuytren’s Contracture

Answer 54

Fixed flexion contracture of the hand most common in 4th & 5th fingers Nodular thickening of the palmar fascial cords causes ocntracture of the fingers Males > Females Bilateral in just under 50% of patients Surgical release is the definitive treatment

Question 55

OA of the Hand & Wrist | What are common findings?

Answer 55

Common disorder in the elderly Seen on xray in > 80% of patients older than 65 y/o, but not all are symptomatic Males > Females in patients < 45 y/o Females > Males in patients > 45 y/o DIP>PIP>1st CMC Can be the result of previous trauma, generalized OA, avascular necrosis, or unknown etiology Heberden’s Nodes occur at the DIP joint Bouchard’s Nodes occur at the PIP joint Osteophytes cause angular deformities, stretching of the ligaments & tendons, loss of ROM, & weakness

Question 56

Treatment of OA of the Hand and Wrist?

Answer 56

Conservative treatment includes NSAID’s, splinting, Occupational therapy, & use of assisted devices Steroid injections are usually not helpful Surgical Procedures: Arthrodesis (fusion procedures) Last resort to relieve the pain Rate of non-union is high (15%)

Question 57

First CMC Joint (Thumb) OA

Answer 57

Affects many post-menopausal women Pain is aggravated by pinch or grasping maneuvers such as opening jars Nocturnal pain is common Weakness is common Obvious deformity is usually present There is tenderness & crepitus at the 1st CMC joint Steroid injections are more helpful NSAID’s & splinting with thumb spica may help in acute flares Surgical treatment is excision of Trapezium to open up the space or occasionally arthrodesis

Question 58

DeQuervain’s Tendonitis

Answer 58

1st dorsal compartment tenosynovitis (inflammation of the tendon sheath) Overuse syndrome of the thumb Pain is in the anatomical snuff box & wrist May feel crepitus or a squeak with movement of the thumb Finklestein’s test is positive Conservative treatment includes thumb spica splint or brace, NSAID’s, ice, & rest Steroid injection if conservative treatment fails Surgery to open tendon sheath if all else fails

Question 59

``` Carpel Tunnel Syndrome is what? Who does this occur in? What 2 tests would be positive? Gold standard for Dx? Treatment? ```

Answer 59

Median nerve compression at the carpal ligament h/o pain & numbness in the median nerve distribution of the index & middle finger, part of the thumb, & sometimes part of the ring finger Can occur in patients that use their hands for work & activities Thenar atrophy Nocturnal pain & numbness Weakness of the hand Positive Phalen’s Test &/or Tinel’s Sign Gold standard for dx is EMG Conservative treatment with velcro wrist splints at night & activity modification Steroid injections sometimes helpful Definitive treatment is carpal tunnel release

Question 60

Cubital Tunnel Syndrome is what? When is pain worse? What test will be positive? Treatment?

Answer 60

Ulnar nerve compression at the elbow in the ulnar groove Pain & paraesthesias over the ulnar nerve distribution in the 5th finger & half of the 4th finger Worse at night Hand weakness Pain is worse with elbow flexed May be related to trauma Atrophy of intrinsic muscles of the hand Positive Tinel’s sign at the ulnar groove Treatment is night splint to prevent elbow flexion & therapy Surgical decompression & ulnar nerve transplant for those who fail conservative treatment

Question 61

Paronychia How does it present? Treatment?

Answer 61

Soft tissue infection localized to the proximal or lateral nail fold Usually have fluctuant mass or visible pus Redness, pain, swelling & tenderness to palpation S. aureus/MRSA most common Definitive treatment is I&D with digital block with culture & sensitivities Antibiotics for 5 days to cover Staph/MRSA include Cephalexin, Doxycycline, Trimethoprim/Sulfamethoxazole

Question 62

What is a Felon? What is the Treatment How does it present? What is the MC cause?

Answer 62

Closed space infection of the pulp of the finger S. aureus most common cause Untreated may lead to decreased blood flow & necrosis of the skin Wooden splinters & minor cuts account for 50% of the causes but the other 50% is unknown Characterized by throbbing pain, tension, & edema of the fingertip pulp Longitudinal incision in the midline at the point of maximal tenderness that does not cross the DIP joint is most effective for I&D Pack loosely with gauze & change every 2-3 days Antibiotics to cover S. aureus/MRSA

Question 63

Herpetic Whitlow

Answer 63

Viral Infection AKA digital herpes Common in children Self spread from lips with thumb sucking or touching sores Often spreads when the skin is cracked Common in health care workers especially in dental practice Intensely painful sore (vesicles may coalesce) Self limiting (2-3 weeks) Antivirals may shorten the course Prevent spread to others

Question 64

5 P's of Acute Compartment Syndrome?

Answer 64

1. Pain out of proportion 2. Pallor 3. Paraesthesias – usually one of the first signs 4. Pulselessness – usually a late sign 5. Paralysis – usually a late sign

Question 65

Acute Compartment Syndrome | Treatment?

Answer 65

Caused by a crush injury or tight bandage/splint/cast May occur in area of any long bone injury (forearm, humerus, tibia, femur) Five P’s Measure compartment pulses > 30 mmHg Absolute emergency Treatment is surgical decompression via fasciotomy

Question 66

What is a Fasciotomy?

Answer 66

An incision is made to open the skin and fascia covering the affected compartment Sometimes, the swelling can be severe enough that the skin incision cannot be closed immediately The incision is surgically repaired when swelling subsides Sometimes a skin graft is necessary

Question 67

Chronic Compartment Syndrome?

Answer 67

``` Chronic compartment syndrome causes pain or cramping during exercise This pain subsides when activity stops It most often occurs in the leg. Symptoms may also include: Numbness Difficulty moving the foot Visible muscle bulging ```

Question 68

Non surgical Treatment of Chronic Compartment Syndrome?

Answer 68

Physical therapy, orthotics (inserts for shoes), and anti-inflammatory medicines are sometimes suggested but, have had questionable results for relieving symptoms Symptoms may subside by avoiding the activity that caused the condition Cross-training with low-impact activities may be an option Some athletes have symptoms that are worse on certain surfaces (concrete vs. running track, or artficial turf vs. grass) Symptoms may be relieved by switching surface

Question 69

Surgical Treatment of Chronic Compartment Syndrome?

Answer 69

If conservative measures fail, surgery may be an option Similar to the surgery for acute compartment syndrome, the operation is designed to open the fascia so that there is more room for the muscles to swell. Usually, the skin incision for chronic compartment syndrome is shorter than the incision for acute compartment syndrome Typically an elective procedure -- not an emergency