UE Part 2 Flashcards
(183 cards)
1
Q
Bones of the elbow
A
- humerus
- Radius
- ulna
2
Q
Ligaments of the elbow
A
- ulnar collateral ligament
- radial collateral ligament
- annular ligament
3
Q
joints of the elbow and their function
A
- ulnohumeral and radiocapitellar articulation: flexion/extension of the elbow and pronation/supination of the forearm
- Proximal radioulnar articulation: pronation/supination of the forearm
4
Q
what does the radius articulate with
A
capitulum
5
Q
what does the ulna articulate with
A
trochlea
6
Q
nerves of the elbow
A
- ulnar
- median
- radial
7
Q
arteries of the elbow
A
brachial branches into
* radial
* ulnar
8
Q
where does the biceps brachii originate and insert
A
long head intertubercular groove
short head coracoid process
inserts on the radial tuberosity and biceps aponeurosis
9
Q
where does the triceps brachii originate and insert?
A
long head originates on lateral aspect of scapular
lateral head on posterior humerus
attaches on olecranon via triceps tendon
10
Q
where are the flexor muscles located?
A
Anterior aspect
11
Q
where are the extensor muscles located
A
posterior aspect
12
Q
what cushions the olecranon and should not be palpable in normal patients?
A
olecranon bursa
13
Q
imaging of elbow
A
- Standard X-rays: AP and lateral
- Oblique (radiocapitellar) 45 degree view –> improved radial head visualization
14
Q
How should the anterior humeral line and the radiocapitellar line align on lateral xray
A
- Anterior humeral line should bisect the middle third of the capitellum
- Radiocapitellar line (drawn through enter of radius) should pass through center of capitellum
- Disruption of these relationships may indicate fracture
anterior humeral line = anterior humerus
15
Q
What are the most common chief complaints of elbow
A
- Pain
- Stiffness
- Swelling
16
Q
What does pain on the posterior aspect of the elbow indicate?
A
- Ulnar nerve compression
- Olecranon bursitis
- Fracture of olecranon
17
Q
What does pain of the medial elbow indicate?
A
- Arthritis
- Ulnar collateral ligament tear
- Medial epicondylitis
18
Q
What does pain of the anterior elbow indicate
A
Arthritis
Rupture of the distal biceps tendon
Pronator syndrome
Lateral epicondylitis
19
Q
What does pain of the lateral elbow indicate
A
- Fracture of the distal humerus
- Fracture of the radial head
- Posterior interosseous nerve syndrome
- Olecranon bursitis
20
Q
Physical exam of elbow
A
Normal ROM
* 0-150 degree flexion
* 10-15 degree hyperextension
* 80 degree supination/pronation
* Inspect
* Palpate
* ROM
* Muscle strength
21
Q
What muscles/nerves can be tested in elbow?
A
- Flexion and supination: bicep, C5-C6, musculocutaneous nerve
- Extension: tricep, C7-C8
- Pronation: pronator teres muscles, median nerve, C6-C7
22
Q
What does valgus stress test of the elbow test?
A
- Stability of medial ligamentous structures, primarily ulnar collateral ligament
23
Q
How is valgus stress test of elbow performed?
A
- Hold elbow in 20 degree flexion with forearm in supination
- Apply pressure on Lateral side of elbow attempting to open the medial joint line
24
Q
What does varus stress test determine?
A
- Stability of the lateral collateral ligament and lateral capsule
25
How is the varus stress test performed?
* Hold elbow in 20 degree flexion with forearm in supination and apply pressure on the medial side of the elbow, attempting to open the lateral joint line
26
Disorders of the elbow
* Fractures
* Subluxation of radial head
* Epicondylitis
* Olecranon bursitis
27
Etiology of distal humeral fractures
* Direct trauma
* Axial loading transmitted through the elbow
28
Types of distal humeral fractures
* Supracondylar (MC in children): type A
* Epicondylar (medial or lateral): type B
* Intercondular: type C (MC) both epicondyles impacted
29
Distal humeral fracture complications
* Intra-articular or comminuted fractures
* Nerve injury to ulnar or radial nerve
30
How would ulnar nere injury present?
* Sensory changes to medial 2 fingers
* Flexion/adduction of wrist impacted
* 4th and 5th DIP joint flexion impacted
* Finger abduction
31
How does radial nerve injury present?
* Sensory changes to dorsal thumb, pointer finger and middle of middle finger and wrist
* Motor: wrist extension
32
Presentation of distal humeral fractures
* Pain
* Swelling
* Tenderness
* Ecchymosis
* Crepitus
* Elbow ROM limited
* Shortening of arm with displaced shaft fracture
33
What should be assessed on exam of distal humeral fracture?
* Skin
* Joints/bones above and below
* N/V status
34
What can be impacted with a supracondylar fracture?
* Radial artery
* Median nerve
35
What can be impacted in an epidconylar fracture?
* Ulnar nerve (medial)
* Radial nerve (lateral)
* depennding on epicondyle impacted
36
Imaging for distal humeral fracture
* AP and lateral elbow x-ray
* Look for fat pad "sail sign"
* MC in kids
37
What does the fat pad sail sign indicate?
Intra-articular bleeding
38
Management of supracondylar fracture?
* Isolated without displacement or angulation: long arm cast/splint with elbow flexed at 90 degrees
* Displaced, angulated, or NV compromise: ORIF
39
Management of epicondylar humeral fracture
* Isolated, minimally displaced: long arm cast/splint with elbow at 90 degrees
* Medial condyle fracture: forearm in pronation
* Lateral condyle fracture: forearm in supination
* Moderate displacement (2-4 mm): percutaneous pinning or ORIF
* Severe displacement: ORIF
40
Long arm posterior casting indications
Supracondylar distal humerus, olecranon, proximal mid-shaft radius and ulnar fractures
41
MOI of olecranon fracture
* Fall on a semi-flexed supinated forearm (avulsion) MC
* 2nd MC: direct trauma
42
Presentation of olecranon fracture
* Pain, tenderness, swelling, ecchymosis over olecranon process
* Limited ROM of elbow
* Deformity if associated elbow dislocation
43
Exam of olecranon fracture
* Assess distal NV status and overlying skin
* Ulnar nerve most often affected
44
Olecranon fracture imaging
* AP and lateral elbow
* Radiocapitellar view if unclear or complicated presentation
45
Management of nondisplaced olecranon fracture (<1-2 mm displacement)
* Posterior long arm splint with elbow in any degree of flexion, forearm in neutral position
* Monitor for vascular compromise
* Encourage hand/finger ROM/strength
* Repeat x-ray in 7-10 days to ensure alignment intact
* Cast/splint removed after 2-3 weeks
* Start gentle ROM therapy
* Consider PT referral
46
Management of displaced olecranon fracture
* Closed: splint and refer for ORIF
* Open: admit for IV abx and consult ortho
* If contraindication for surgery, sling and start ROM as pain allows
47
Complications of olecranon fracture
* Elbow stiffness, loss of ROM
* Arthritis
* Non-union
* Surgical implant failure
48
MOI of radial head/neck fracture
fall on outstretched hand resulting in compression of radial head into the capitellum
Most common fracture of the elbow
49
Classification of radial head/neck fracture
* Mason classification
* Type I: <2 mm displacement
* Type II: displacement > 2 mm
* Type III: comminuted
* Type IV: radial head fracture with associated elbow dislocation
50
Presentation of radial head/neck fracture
* Pain and tenderness along lateral aspect of elbow over radial head
* Limited ROM related to pain or joint effusion
* Painful pronation/supination
* +/- local swelling/ecchymosis
* Additional exam: assess bones and joints above and below, skin, NV status
51
Imaging of radial head/neck fracture
* AP and lateral elbow with fracture line, fat pad sign
* Capitellar view if unable to appreciate fracture on standard views
52
Management of type I radial head/neck fracture
* Sling with or without a posterior splint --> splint should be removed after 1-2 days
* AROM after 24-48 hours with full extension, flexion; pronation and supination with elbow flexed at 90 degrees
* F/U with ortho in 1 week
* Aspiration if hemarthrosis is present to allow early ROM
53
Management of type II-III radial head/neck fracture
* Sling and splint with ortho evaluation in 2-3 days to discuss consideration of ORIF
* Ortho can assess for mechanical block
54
Management for type IV radial head/neck fracture
Immediate consult for reduction and ORIF
55
What is radial head subluxation?
* AKA nursemaid's elbow
* Subluxation of the radial head through annular ligament due to laxity
* MC in children under 5
56
MOI of radial head subluxation
* Pulling on a pronated forearm while the elbow is extended
57
Clinical presentation of radial head subluxation
* Hx of mechanism followed by crying which subsides quickly
* Arm held semi-flexed, adducted, and pronated
* ROM is refused: resistance with attempted supination
* Tender over radial head
* No swelling or ecchymosis
58
Imaging of radial head subluxation
* Not necessary for diagnosis
* X-ray only if suspicion of other injury
59
Management of radial head subluxation
* Reduction
* If failed reduction, order radiographs, splint, and refer to ortho
* If succesful reduction, tylenol/motrin prn +/- sling, parent education
60
How can radial head subluxation be reduced?
* Premedicate with tylenol or motrin
* 2 techniques: supination-flexion or hyperpronation
* Immediate re-assessment of NV status
* After 15-30 minutes reattempt if no improvement, 3-4 attempts acceptable
* Reduction less likely to be successful if seen 1-2 days after injury
61
Supination-flexion reduction technique
1. Hold elbow with thumb over radial head
2. Quickly supinate fully
3. Folowed by complete flexion
62
Hyperpronation reduction technique
* Hold elbow with your thumb overlying radial head
* Hyperpronate forearm
* Followed by complete extension then flexion
* EBM states that this technique is often more effective than the first and may be less painful
63
What is epicondylitis
* Tendinosis of wrist extensors or wrist flexors at their origination site on their respective epicondyles
* Lateral: wrist extensors (tennis elbow) MC
* Medial: wrist flexors (golfers elbow)
64
MOI of epicondylitis
* Chronic repetitive overuse resulting in micro-trauma at tendon insertion
* Acute strain due to excessive loading
65
Epidemiology of epicondylitis
* MC between 30-50 years of age
66
Presentation of lateral epicondylitis (tennis elbow)
* Pain with wrist extension and gripping- shaking hands, using computer mouse, use of screwdriver, back-handed tennis swing, opening jar
* Paint tenderness 1 cm distal to epicondyle
* Pain with wrist extension and supination against resistance (elbow extended)
67
Presentation of medial epicondylitis
* Pain with arm pronation and wrist flexion, grip pain/weakness-golf swing, overhead throwing, bowling
* Point tenderness 1 cm distal to epicondyle
* Pain with wrist flexion and pronation against resistance (elbow extended)
68
Diagnostics for epicondylitis
Normal AP and lateral elbow (not needed for diagnosis)`
69
Management of epicondylitis
* Activity modification, NSAIDs, ice after use
* Refer to PT if failure of conservative treatment
* PT after initial pain subsides: gentle stretching and strengthening
* Bracing: counterforce brace
* Steroid injection x 3 max
* Refer to ortho if symptoms persist for 6 months of conservative therapy
70
What is olecranon bursitis
Inflammation of the olecranon bursa
71
Mechanism of olecranon bursitis
* Trauma: fall or direct blow to elbow
* Inflammation: excessive leaning on elbow or secondary to systemic inflammatory conditions (RA, gout, etc)
* Infection: septic bursitis, MC pathogens staph and strep
72
Presentation of olecranon bursitis
* Gradual or sudden swelling of the brusa up to 6 cm in daimeter
* Small lumps of scar tissue remain as swelling subsides
* +/- pain, tenderness, limited ROM: more so in trauma and infectious etiologies, chronic recurrent swelling is less tender
* Redness and warmth in acute bursitis
73
Diagnostics for olecranon bursitis
* Aspiration for large, symptomatic bursa
* AP and alteral elbow x-ray if hx of trauma
74
What analysis is performed on bursal fluid
* CBC
* Gram stain
* C&S
* Crystals
75
Management of inflammatory or traumatic olecranon bursitis
Mild swelling
* Activity modification and NSAIDS
* Use of elbow pad, compression during acute phase
Significant swelling
* Aspirate, apply compression bandage, and f/u in 2-7 days
* If fluid returns and cultures are negative repeat aspiration and re-culture
* If cultures remain negative but swelling persists, aspiration and injection of 1 mL of corticosteroid into the bursal sac
76
Management of mild, with no immunosuppression, septic bursitis
* Bactrim or keflex
* Abx tailored to culture and sensitivity once available
77
Management of severe bursitis or immunosuppression
* IV vancomycin
* Add pseudomonal coverage if associated with trauma ie ciprofloxacin or zosyn
* Abx tailored to culture and sensitivity once available
78
What are indications of a severe presentation of septic bursitis
* systemic toxicity (fever, hypotension, tachycardia)
* rapid progression or progression 48 hours after abx
* unable to tolerate oral therapy
* close indwelling medical device ex prosthetic joint or vascular graft
79
forearm anatomy
80
forearm series imaging
AP and lateral
81
Hand, wrist, and finger series imaging
PA
Oblique
Lateral
82
MOI of forearm fractures
* Direct blow
* Fall on outstretched hand
83
Complicated forearm fractures
* Galeazzi: radial midshaft with instability of distal radioulnar joint
* Monteggia: proximal third of ulnar shaft with dislocation of radial head due to instability of the proximal radioulnar joint
## Footnote
MUGR
84
Diagnosis of forearm fracture
* Forearm series: should provide you a view of the wrist and elbow
* Add dedicated elbow or wrist if needed to further evaluate the joint
84
Forearm fracture presentation
* Deformity
* Swelling
* Ecchymosis
* Point tenderness overlying fracture
* Decreased ROM of joint above and below
* Assess NV status
* Assess compartments of forearm
85
Indications for emergent (<1 hour) orthopedic referral for forearm fracture in adult
* Arterial compromise
* Open fracture
86
Indications for urgent referral to ortho (<24 hours) for forearm fracture ina dult
* Ulnar shaft fracture with <50% apposition or >10 degrees angulation
* Forearm fracture with any DRUJ or PRUJ instability
* Forearm fracture with peripheral nerve injury
* Both bones fracture with displacement
87
Indications for priority orthopedic referral for forearm fracture in adult
* Isolated radial shaft fracture with any displacement
* Both bones fracture even with minimal or no displacement
* Isolated proximal third ulna fracture
88
Management of simple, isolated fracture of the ulnar shaft
* <50% displacement, <10% angulation before or after closed reduction and no joint involvement
* Long-arm posterior splint: elbow at 90 degrees, forearm in neutral position, slight wrist extension
* After 1-3 weeks remove splint and place in a functional forearm brace for 4-6 weeks to allow protected AROM of the elbow, forearm, and wrist
* F/u to ensure alignment at 1 week and then q 4 wk until complete healing has occured, usually 8 weeks
89
Management of isolated radial fractures, combined radius-ulna fracture, or galeazzi or monteggia fracture
* Double sugar tong
* Combined radius-ulna fracture and galeazzi or monteggia, refer to ortho
90
Wrist bone anatomy review
scaphoid
lunate
triquetrum
pisiform
trapezium
trapezoid
capitate
hamate
lateral to medial proximal line then distal
## Footnote
some lovers try positions they can't handle
91
What are the 2 ligaments of the wrist?
Ulna collateral and radial collateral
92
What is the ulnar nerve area of sensation?
* Ring finger and pinky finger
93
What is the median nerve area of sensation
* Thumb and first 2 fingers
94
What is radial nerve area of sensation
dorsal thumb and first 2 fingers
95
What is the palmar blood flow
* Ulnar and radial artery
* Deep and superficial palmar arch
* CCommon palmar digital arteries and proper palmar digital arteries, radial artery index finger
96
What is the dorsal wrist blood flow?
* Radial artery
* Basal metacarpal arch
* Dorsal metacarpal arteries
* Digital arteries
97
MOI of wrist fracture
Fall on outstretched hand
98
Common types of wrist fractures
* Colles fracture: distal radius fracture fragment tilted dorsally
* Smith's fracture: distal radial fragment tilted volarly
99
What is a dinner fork derormity?
Colles fracture
100
What is a garden spad deformity?
Smith's fracture
101
Presentation of wrist fracture
* acute pain
* tenderness
* swelling
* deformity of the wrist
102
diagnostics of wrist fracture
wrist x-ray series
103
wrist fracture management for nondisplaced or minimally displaced and non-articular fractures
* sugar tong splint or short arm cast for 2 to 3 weeks
* Casts should not be placed until 72 hours after injury
* AP and lateral radiographs should be performed each week for 2 weeks to assure union and reduction
104
management for displaced and open fractures
ORIF
105
epidemiology of scaphoid fracture
* MC carpal fracture
* MC in young men
106
MOI of scaphoid fracture
* Hyperextension injury
* fall on outstretched hand
107
Anatomic considerations of scaphoid fracture
Blood supply enters at the distal 1/3 of the bone
108
Complications of scaphoid fracture
* High incidence of delayed diagnosis
* Non-union
* Avascular necrosis
109
Presentation of scaphoid fracture
* Wrist pain/swelling along radial aspect
* Tenderness along anatomical snuff box
* Grip and ROM may be painful/weak/limited
110
Scaphoid fracture diagnostics
* Wrist series plus
* Scaphoid (navicular) view: PA view with the wrist in ulnar deviation
* CT/MRI if x-rays remain negative and suspicion is high
111
Management of nondisplaced or negative x-rays scaphoid fracture
* Thumb spica splint/cast x 6 weeks
* Refer to ortho
* Repeat x-rays in 7-14 days if initially negative
* If x-rays remain negative and tenderness persists --> CT/MRI
* Monitor for complications and to ensure complete healing with serial x-rays/MRI
112
Management of displaced scaphoid fracture
* ORIF
* Percutaneous pin placement
* Monitor for complications and to ensure complete healing with serial x-rays/MRI
113
Indications for thumb spica splint
* Scaphoid
* Lunate
* Trapezium
* 1st metacarpal
* 1st phalynx bone fractures
* 1st MCP dislocation
* Ulnar collateral ligament tear
* De Quervain's tenosynovitis
114
What is carpal tunnel syndrome?
* Compression of the median nerve at the carpal tunnel
115
Risk factors for carpal tunnel syndrome
* Repetitive wrist movements
* Wrist injury
* Pregnancy
* Sedentary lifestyle
* Familial
* Multiple systemic conditions
116
Presentation of carpal tunnel syndrome
* Burning, tingling pain over median nerve distribution of the hand
* Exacerbated by activity and at night
* Aching pain radiating to elbow and shoulder
117
Physical exam of carpal tunnel syndrome
* Tinel's and Phalen's signs
* Carpal compression test
* Hand elevation test
* Grip weakness
* Thenar atrophy (late)
118
Diagnosis of carpal tunnel syndrome
EMG/NCS
119
Management of carpal tunnel syndrome
* Activity modification
* Cock-up wrist splint
* Corticosteroid injection
* Refer for to ortho for carpal tunnel release
120
Indications for referral to ortho for carpal tunnel release
* Failure of >3 months of conservative therapy
* Objective neurologic findings of thenar muscle atrophy
121
Anatomy review of hand bones
122
What is the epidemiology of metacarpal factures?
Most common in adults
123
What is the most common fracture in the hand?
Boxer's fracture: fracture of 4th or 5th metacarpal that results from a closed fist striking a object
124
What is the epidemiology of phalangeal fractures?
MC in children, involving the physis of the 5th phalange
Distal phalynx most commonly injured in adults
125
Presentation of metacarpal/phalangeal fractures
* History of trauma
* Local tenderness, swelling, deformity, and decreased ROM
* Boxer's fracture most likely to be malrotated
* Assess distal NV status
126
Management of displaced metacarpal neck fracture
>30 degree angulation --> reduction followed by splint/casting
<30 degree angulation --> splint for 2-3 weeks. If 4th or 5th metacarpal, ulnar gutter splint; if 2nd and 3rd metacarpal --> radial gutter splint
127
Management of non-displaced metacarpal/phalangeal fractures
* Non-displaced fractures of the 2-5th metacarpal/phalangeal shaft: splint for 3-4 weeks
* Gutter splint: metacarpal
* Phalangeal fracture: buddy tape or aluminum splint
* Non displaced fracture of 1st metacarpal/phalange: thumb-spica splint, wrist in 30 degrees of extension
* Non-displaced/non-articular 1st metacarpal base: thumb spica splint/cast x 4 weeks
*
128
Management of displaced/angulated metacarpal/phalangeal shaft fracture or intra-articular fractures
* Refer/consult ortho for further evaluation
* Closed vs open reduction and fixation
129
Pathology of Gamekeeper's thumb aka skier's thumb
Rupture of the ulnar collateral ligament of the 1st MCP joint
130
MOI of Gamekeeper's Thumb
Forced radial abduction
131
Clinical presentation of gamekeeper's thumb
* Pain, swelling, tenderness along the medial 1st MCP joint
* Weak pincer formation
* Stress testing after local anesthesia
132
Diagnostics of Gamekeeper's thumb
1st phalange finger series
133
Management of gamekeeper's thumb
Thumb spica splint
Refer to ortho for surgical repair
134
Pathology of Mallet finger
* Rupture, laceration, or avulsion of the extensor tendon at the distal phalanx
135
MOI of Mallet finger
Hyperflexion of DIP
136
Clinical presentation of mallet finger
* DIP is flexed at 40 degrees with the inability to actively extend
* PROM is intact
* Mild tenderness over dorsal DIP
* May be associated with an avulsion fracture of distal phalanx
137
Mallet finger diagnostics
Finger series rule out avulsion fracture
138
Management of Mallet finger
* Finger splint DIP in full extension x 4-8 weeks
* Splint can not be removed
* If not treated properly will result in swan neck deformity: hyperextension of PIP with flexion of DIP
139
Pathology of Boutonniere deformity
Rupture of the central slip of the extensor tendon where it inserts on the middle phalanx
140
MOI of boutonniere deformity
Forced flexion of the PIP
141
Presentation of Boutonniere deformity
* Finger is held partially flexed at the PIP and extended or hyperextended at the DIP
* May not be as noticeable with swelling
* Swelling, pain along dorsal PIP
* Point tenderness along dorsal PIP
* Limited ROM and inability to fully extend the PIP, remains flexed at 30 degrees
142
Diagnostics of Boutonniere deformity
* Finger series to r/o avulsion fracture
143
Management of Boutonniere deformity
Finger series to r/o avulsion fracture
144
Management of boutonniere deformity
* Splint PIP in extension leaving DIP free x 4-8 weeks
* Refer to ortho if indicated
145
When would you refer to ortho for Boutonniere deformity?
* If conservative therapy fails
* Associated irreducible PIP dislocation
* Associated open fx
146
What is dequervain tenosynovitis
* Inflammation of the tendon sheath covering the extensor/abductor tendons of the thumb
147
Etiology of de quervain tenosynovitis
Overuse syndrome
148
Presentation of de quervain tenosynovitis
* Aching pain and point tenderness along the radial aspect of the wrist with use
* Pain may radiate up arm
* Thickened 1st dorsal compartment creating a prominence at the radial styloid
* Finkelstein test is diagnostic
149
What is a postiive Finkelstein test
Ulnar deviation of an adducted thumb reproduces pain
150
Management of De Quervain tenosynovitis
* Thumb spica splint
* Activity modification
* NSAID's
* Refer to ortho if conservative therapy fails for corticosteroid injections into tendon sheath and surgical release of the first dorsal compartment
151
What is a ganglion cyst
* Fluid-filled swelling overlying a joint or tendon sheath filled with clear, gelatinous, sticky, or mucoid fluid
152
MC location of ganglion cyst
Dorsal aspect of the wrist
153
Epidemiology of ganglion cyst
MC in females aged 10-40`
154
Pathogenesis of ganglion cyst
Unknown, but thought to occur as result of mucoid degeneration of periarticular structures
155
Clinical presentation of ganglion cyst
* Localized intermittent pain/tenderness
* Cyst is firm, smooth, rounded, rubbery
* May fluctuate in size over time
* Transillumination will help differentiate cyst from solid lesion
156
Diagnostics for ganglion cyst
* X-ray to rule out bony pathology
* US or MRI if atypical presentation
157
Management of ganglion cyst
* Observation: most will spontaneously regress
* Aspiration, with or without injection of a corticosteroid
* Surgical removal
158
What is trigger finger
* Idiopathic dysfunction of flexor tendon of finger as it glides through the tendon sheath
* Often due to a discrepancy in size of the tendon and its sheath
* 3rd and 4th digits most commonly affected
159
Presentation of trigger finger
* Catching, snapping, or locking of the involved finger
* Worse upon awakening
* MOre than one finger may be affected
* Associated with pain and dysfunction
* Painful nodule on the palm
160
Management of trigger finger
* NSAIDs, +/- corticosteroid injection into the tendon sheath
* If symptoms persist, a second injection may be considered in 3 to 4 weeks
* Patients with RA are at risk for tendon rupture and should only have one injection
* Failure of conservative therapy --> surgical release considered
161
What is dupuytren contracture?
Progressive fibrosis of the palmar fascia
162
Epidemiology of dupuytren contracture
Men >50 years old
163
Risk factors for dupuytren contracture
* Epilepsy
* DM
* Pulmonary disease
* Alcoholism
* Smoking
* Repetitive vibrational trauma
164
What is the most common phalange affected by dupytren contracture
4th phalange
165
Presentation of dupuytren contracture
* One or more painless nodules near the distal palmar crease
* Nodules gradually thicken leading to a cord that contracts
* Flexion normal, but extension limited
166
Diagnostics for dupuytren contracture
Clinical diagnosis no other testing needed
167
Management of dupuytren contracture
* Night splinting may slow progression
* Surgery release if 30 degree fixed flexion of MCP, involves excising thickened soft-tissue bands and release of joint contractures
168
BRACHIAL PLEXUS
AHHHH
169
What is brachial plexus syndrome
Damage to brachial plexus
170
MOI of brachial plexus syndrome
* Traction force: shoulder depressed and head/neck tilted to opposite side to damage C5, C6, and C7 roots
* Direct blow to top of shoulder damages C5, C6, and C7
* Stretching of the plexus when arm abducted forcefully ie grabbing something while falling damages C8 and T1
171
Presentation of brachial plexus syndrome
* Sharp, burning shoulder pain with radiculopathy in the affected nerve root distribution
* Weakness is common
172
Physical exam of brachial plexus syndrome
* Evaluate sensation, motor function, DTR
* Injuries to C8-T1 can be associated with Horner's sundrome d/t preganglionic injury and sympathetic chain disruption
* Assess lower extremities for spinal cord involvement: spasticity or weakness in ipsilateral leg suggests spinal cord injury
* Look for associated injuries
173
S/S of Horner's syndrome
* Ipsilateral ptosis
* Myosis
* Anhidrosis
* Enophthalmos
174
Diagnostics of brachial plexus syndrome
* X-rays: c-spine and shoulder
* CT c-spine: rule out c-spine fractures if x-ray abnormal
* MRI: for visualizing spinal cord and nerve roots if x-rays are abnormal or symptoms persist
* EMG/NCS: may help differentiate location of nerve dysfunction
175
Management of brachial plexus syndrome
* Typically conservation: stretch and strengthen, splint in neutral position of any joints affected by paralyzed muscles
* Encourage PROM to reduce joint stiffness or tendon constrictures
* Athletes must have complete resolution of symptoms and normal PE before allowed to return to activity
176
What are the structures of the thoracic outlet?
* First rib
* Subclavian artery and vein
* Brachial plexus
* Clavicle
* Lung apex
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What is thoracic outlet syndrome?
* Compression of the brachial plexus and/or subclavian vessels as they exit the narrow space between the superior shoulder girdle and the 1st rib
* Most commonly affects women 20-50 yo
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Clinical presentation of thoracic outlet sydnrome
* Compression of the brachial plexus
* Aching pain/paresthesia
* Compression of the vascular structures: intermittent swelling and discoloration
* Fatigue, weakness, and aching pain of extremity
* Symptoms often exacerbated by lifting arm above the head
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Physical exam of thoracic outlet syndrome
* Inspect for swelling/discoloration
* Palpate the supraclavicular fossa to assess for a mass
* Palpate for distal UE pulses
* Check sensation and motor function cervical nerve roots
* Elevated arm stress test
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What is the elevated arm stress test
Both shoulders abducted at least 90 degrees and supported posteriorly the patient opens and closes fists at a moderate speed for 3 minutes.
Positive if reproduced neuro and/or vascular s/s
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Diagnostics for thoracic outlet syndrome
* AP and lateral c-spine to rule out congenital anomalies
* PA/lateral CXR to help rule out apical lung tumors
* MRI to rule out cervical disc rupture or cervical spondylosis
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Management of throacic outlet syndrome
* Non-surgical (most patients): 3-6 months of home exercise programs emphasizing muscle strengthening and posture
* Avoid strenuous activities, placing straps over shoulders, and any activity that exacerbates symptoms
* NSAIDs, muscle relaxers, TENS unit
