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Flashcards in UE ortho Deck (70):
1

broad categories for shoulder pain

arthritic picture
impingement
rotator cuff injury

2

what are we worried about with impingement

i. Subacromial bursitis
ii. Rotator cuff tendonitis
iii. Biceps tendonitis

3

suction cup that holds the rotator cuff and the capsule attaches to

the labrum

4

impingement pain would be described as

pain with reach for a seat belt
hooking a bra
throwing a ball
inability to sleep on shoulder
pain that radiates from the top of the shoulder to the bicept

upper neck and back pain
loss of strength and motion

5

with frank weakness in the shoulder

we worry about a tear

6

with difficulty because of pain

worry about impingement

7

physical exam

look for TTTP around sub-acromial area
looking at passive or active
strength testing (out of 5)

" Inspect for any visible deformity
" Palpate for any point tenderness over biciptal groove, AC joint, posterior subacromial area
" Passive and active ROM
" Strength testing
" Special tests: Jobe (empty can), Neer, Hawkins, Speeds, Cross-body Adduction, Drop Arm

8

joeb or empty can

abduction against resistance with internal rotation
rotating the humeral head will allow for better understanding of impingement

positive test tells you
rotator cuff

9

Neer

internal rotation thumb down
examiner supports the scapula while lifting the arm (passive)
looking to see if it ellicits pain

also looking for impingement rotator cuff

10

Hawkins

internal rotation with flextion 90 degree angle robot wave


examiner hands on bicept and forearm (rotator cuff)

11

Speeds

for bicepts tendon

12

Cross-body Adduction

mostly used for AC joint
palpate AC joint and cross arm with 90 degree angle

13

no joint space at glenohumeral

OA

also visualized with bone spurs

14

impingement tx

course of anti inflammatories
cortisol injection if no relief with oral NSAIDs in 4-6 weeks
can take 2-3 for cortisone to work
if continued need to rule out a cuff tear with an MRI

15

what population would you want to avoid cortisone with

DM population-A1C over 9 absolutely, reconsider over 8
high risk for bacterial infection

16

orthopedic managment of anterior

a. Anterior dislocation: conservative management
b. Short period of immobilization
c. Gradual advance to passive rom, then active rom, then advance to strengthening
d. Can be a long 3-5 month process
e. If continued instability 6 months plus after injury than refer to surgeon

17

orthopedic management of posterior

a. Not as common, I always review these with surgeon on first visit and defer to their treatment plan

18

what do you need with a gleno-humeral dislocation

XRAy of shoulder to rule out fracture of glenoid humeral head
post reduction films are needed

19

a compression fracture of the posterolateral articular surface of the humeral head

Hill Sachs lesion

20

acromioclavicular MOA

a.Typically caused by direct downward blow to the tip of the shoulder

b.Severity of injury dependent on structures that are compromised

21

CM of acromioclaviuclar injury

" Focal pain and swelling over AC joint
" Pain with attempt at overhead motion of arm or cross-body adduction

22

PE with acromioclaviuclar injury

" Inspect for deformity over AC joint
" Focalized tenderness over AC joint
" With mild injuries can access AC joint with cross body abduction (may be too painful for grade II or higher)

23

dx of acromioclavicualr injury

Diagnostics
1. Xrays: AP, lateral and axillary
2. AP of both shoulders helpful if displacement or widening of joint not obvious

24

tx of acromioclavicular injury

" Non operative (grade I-III)
" Brief period of immobilization, followed by passive range of motion of shoulder and gradually progress to active range of motion with focus on strengthening surrounding structures

25

what is thoracic outlet syndrome

temperature changes and skin color changes might go down this route

26

big cause of olecranon bursitis

GOUT
spider bites
banging the elbow

27

olecranon bursitis what is our red falg

you need to know
NO FEVER NO CHILLS to rule our your seotic arthritis with this

28

CM of olecranon bursitis

" Patients note limited ROM of elbow due to swelling and discomfort
" Not always point tender
" Make sure to ask about fever, chills, nausea, vomiting

29

PE for olecranon bursitis

" Visible large mass over tip of elbow
" Redness or erythema to skin not uncommon

30

Tx for olecranon bursitis

" If mass is small: compression, NSAIDs, ice and limited use of elbow
" If mass is large: aspiration
" Cloudy fluid or suspect infection: send aspirate for cell count, cultures, gram stain and crystals

31

dx tests for olecranon bursitis

joint aspiration if it looks like cottage cheese it's gout

crystals
gram stain
cell count

32

tennis elbow aka

a. Lateral Epicondylitis

33

where does Lateral Epicondylitis and what is it usually due to


Occurs at site of origin of the extensor carpi radialis brevis
sometimes it's just over the tendon and sometimes it moves down into the actual musculature

Due to tissue degeneration with fibroblast and microvascular hyperplasia

34

b. Medial Epicondylitis muscles involved

ii. Occurs in common tendinous origin of flexor/pronator muscles just distal to medial epicondyle
iii. Less common than lateral epicondylitis

35

pain with wrist extension and/or forearm supination

lateral epicondylitis

36

: pain with wrist flexion and/or forearm pronation is suggestive of

medial epicondylitis

37

what would you find in a PE of a pt with condylitis

" Point tender over or just distal to origination of affected musculature
" Pain with resisted wrist and/or forearm action

lateral can see pain with middle finger flexion

38

Treatment for condylitis

NSAIDs
Ice, massage, topical creams
Activity modification

Bracing: elbow strap and or wrist brace will srtop action at brace and allow for rest

Cortisone injection: locate point of maximal tenderness for target spot to inject

Surgery: debridement and possible release of tendon

39

Cubital Tunnel Syndrome

Compression of the ULNAR nerve at the cubital tunnel along the medial aspect of the elbow

40

b. Second most common compression neuropathy in upper extremity

Cubital Tunnel Syndrome

secondary to carpal tunnel

41

when do you typically see cubital tunnel syndrome

Exacerbated by prolonged flexion of elbow
pts at night

42

CM of cubital tunnel syndrome

" Parasthesia and numbness of ring and small fingers
" Nighttime pain

43

VII. Cubital Tunnel Syndrome PE

" Inspect for atrophy of muscles innervated by ulnar nerve
" Palpate nerve to see if it is mobile within the tunnel
" Tinel sign, Elbow flexion test

44

Cubital Tunnel Syndrome dx

nerve conduction study

45

VII. Cubital Tunnel Syndrome TX

" Elbow pad to protect nerve
" Splint for nighttime comfort w elbow in 45 deg flexion
" NSAIDs
" Surgical treatment: decompression (release) or ulnar nerve transposition

46

ulnar nerve respon

pinky and ring

47

compression of the median nerve

a. Compression of the median nerve within the carpal tunnel
VIII. Carpal Tunnel Syndrome

thumb index middle and half of the ring

48

what populations do you typically see carpal tunnel in

Commonly affects middle aged or pregnant women

Often idiopathic but is associated with pregnancy, flexor tenosynovitis, overuse, inflammatory conditions, trauma to the wrist, endocrine disorders and tumors

49

CM of carpal tunnel

" Numbness in thumb, index and middle fingers
" Pain awakens them at nighttime
" Aching pain radiates up arm or into thenar area
" Inability to open jars or clumsiness with holding objects
" Pain with driving or keyboarding

50

durken carpal compression

" Inspect for thenar atrophy
" Phalen maneuver and Tinel sign
" Durkan carpal compression test

51

dx study for carpal tunnel

i. Nerve conduction study

52

carpal tunnel tx

" Bracing (esp nighttime, driving)
" NSAIDs
" Ergonomic modifictions
" Cortisone injection
" Surgical release of fibrous surrounding : open or endoscopi

53

ganglion cysts arise from

a. Arises from the capsule of a joint or a tendon synovial sheath

54

Cyst contain

b. Cyst contains thick, clear, mucinous fluid

55

Most common soft tissue tumors of the hand and wrist

cysts

56

cysts differentiate form cancer

because they are mobile and loose

57

CM of cysts

" Visible mass or lump that may fluctuate in size
" May be painful with range of motion at the affected joint or point tender to pressure

58

PE of cyst

" Soft, mobile mass
" May be multilobulated

59

why does cysts come back

because they have their own lining

60

cysts treatment

" If it is not painful than I tell patients to leave it alone
" If it is causing pain or discomfort can attempt aspiration of cyst (mindful of volar wrist area)
" Surgical excision also an option if aspiration unsuccessful

61

Swelling of sheath that surrounds abductor pollicus longus and extensor pollicis brevis at radial styloid area

X. De Quervain Tenosynovitis

62

De Quervain Tenosynovitis affects what muscles

abductor pollicus longus and extensor pollicis brevis at radial styloid area

the muscles that deviate the wrist and abduct the arm

baby picking up

63

where do we see CM of pain

" Pain, swelling and tenderness over radial styloid
" Pain with thumb flexion, abduction w wrist ulnarly deviated

64

Physical Exam of pts with suspected De Quervain Tenosynovitis

" Finkelstein test: provocative test to produce symptoms. Flex thumb into palm and ulnar deviate the wrist
Usually positive with De Quervains diagnosis

65

De Quervain Tenosynovitis

" NSAIDs, immobilization, physical therapy, activity modification
" Cortisone injection
" Surgery

66

Trigger Finger is inflammation of

Inflammation of flexor tendon or first annular pulley

finger when you try to straighten it catches

67

what SE do you want to warn pts of with cortisone

lightening of the skin
hypopigmentation

68

CM of trigger finger

" Pain, catching or locking when attempt finger flexion
" Painful nodule in the distal palm

69

PE with trigger finger

" Painful palpable nodule at distal palmar crease
" Palpable hitching along flexor tendon as passively flex finger

70

tx of trigger finger

" Cortisone injection into flexor sheath
" Surgical release of A1 pulley if symptoms refractory to injection
Injection technique
" Idea is to bathe tissue with anti inflammatory liquid
" Use 1ml syringe with small needle
" Do not inject fluid directly into tendon