Upper Extremity Flashcards by Zachary Schulz

A 12 y.o. male presents to the ED after a fall directly to his left shoulder. On exam, there is tenting of the skin over the middle third of the clavicle. There is no gross evidence of dislocation and he is neurovascularly intact distally.

What is your suspected diagnosis and what imaging modality is most diagnostic?

Clavicular fracture

How well did you know this?

Not at all

Perfectly

XR shows a non-displaced mid-clavicular fracture.

What is your course of management for this patient?

Would you recommend surgery?

Sling for 4-6 weeks (could consider ‘figure 8-brace’) and PT for strengthening

No, surgery would only be indicated for significant deformity or displacement

How well did you know this?

Not at all

Perfectly

A 18 y.o. male presents to the ED with right shoulder pain. The pain onset after he was checked into the boards during a hockey game 1 hour ago. On Exam, you note a deformity and tenderness over the AC joint. There is pain with cross body adduction on the right. He is neurovascularly intact distally.

What is your suspected diagnosis and what imaging modality would be diagnostic?

AC Separation

How well did you know this?

Not at all

Perfectly

XR shows a grade II AC separation

Which ligament(s) in the shoulder is likely involved?

What would be your course of management?

Acromioclavicular ligament

Sling for 1-2 weeks and PT for strengthening

How well did you know this?

Not at all

Perfectly

XR shows a grade V AC separation

Which ligament(s) in the shoulder is likely involved?

What would be your course of management?

Acromioclavicular and Coracoclavicular ligaments

Surgical reduction and repair

How well did you know this?

Not at all

Perfectly

What is the most common cause of AC joint pain?

Arthritis

How well did you know this?

Not at all

Perfectly

T/F: Repeated overhead use is a risk factor for developing AC joint arthritis

True

How well did you know this?

Not at all

Perfectly

What would you expect to see on XR in AC joint arthritis?

Joint space narrowing +/- spurs

How well did you know this?

Not at all

Perfectly

What medication class is first line for treating AC joint arthritis?

NSAIDs

How well did you know this?

Not at all

Perfectly

A 45 y.o. male presents to your office with increasing right shoulder pain. He has been working as a painter for 15 years, and over the last month, he has had increasing pain in his shoulder. The pain is worse as the day goes to the point wear he cant buckle his seat belt or reach for his wallet by the end of the day. He localizes the pain to his lateral shoulder and radiates to just above the elbow.

What is your expected diagnosis?

Would you expect this patient to have pain with adduction or abduction of the arm?

Shoulder impingement

Pain with abduction

How well did you know this?

Not at all

Perfectly

What physical examination signs would be positive to confirm your suspected diagnosis of shoulder impingement?

Neers

Hawkins

How well did you know this?

Not at all

Perfectly

What imaging study is most diagnostic in confirming your diagnosis?

MRI

How well did you know this?

Not at all

Perfectly

What medication would be first-line in treating this condition?

Other than the above, what procedure could be done in office to improve the pain?

What would be the most ‘disease modifying’ recommendation in this patient?

NSAIDs

Could preform steroid joint injections

Physical Therapy will be most beneficial for this patient

How well did you know this?

Not at all

Perfectly

In a patient with calcific tendonitis…..

What would most likely be seen on XR of the joint?

Calcium deposits

How well did you know this?

Not at all

Perfectly

A 25 y.o. active weight lifter presents with anterior left shoulder pain, which they have noticed is exacerbated when they’re preforming bicep curls. On exam, you note that ROM is limited due to pain and there is pain within the intertuberous groove of the left shoulder.

What is your suspected diagnosis and what two physical examination ‘tests’ would confirm this?

Bicep Tendonitis

Speed’s Test
Yergason’s Test

How well did you know this?

Not at all

Perfectly

A 45 y.o. female presents with right shoulder pain which onset after she tried to lift a heavier box over her head while she was helping her friend move. At that time, she heard something ‘pop’ in that shoulder. She has since noticed significant pain with raising her arm. On exam, there is decreased active ROM secondary to pain. When you passively raise her arms above her head, she is unable control adduction of her left arm and it rapidly falls to her side.

What physical examination test is described above?

Positive drop arm test

How well did you know this?

Not at all

Perfectly

What is your suspected diagnosis and what imaging study would be most diagnostic?

Rotator Cuff Tear

MRI

How well did you know this?

Not at all

Perfectly

What should this patient attempt prior to considering surgical repair?

Physical therapy

How well did you know this?

Not at all

Perfectly

A positive ‘empty can test’ would be consistent with what shoulder condition?

Rotator cuff tear

How well did you know this?

Not at all

Perfectly

Are anterior or posterior shoulder dislocations more common?

How well did you know this?

Not at all

Perfectly

Which nerve may be injured or compromised in a shoulder dislocation?

Axillary

How well did you know this?

Not at all

Perfectly

What is the primary treatment of a shoulder dislocation?

Closed reduction, sling, and refer for PT

How well did you know this?

Not at all

Perfectly

What XR view is needed in diagnosing a posterior shoulder dislocation?

Axillary-lateral View

How well did you know this?

Not at all

Perfectly

A ______ tear is a common complication of a anterior shoulder dislocation

Labral Tear

How well did you know this?

Not at all

Perfectly

Labral tears are often described as a ________ lesion

Bankhart Lesion

A _______ fracture can occur in conjunction with labral tears

Glenoid Fracture

Which ligament of the shoulder may be injured or compromised in anterior labral tears? This is the major stabilizing ligament of the shoulder

Inferior glenohumeral ligament

Anterior labral tears can lead to instability of the joint..... This could result in recurring what?

Dislocations and subluxations

What physical examination tests would induce pain in a anterior labral tear? Which one would relieve the pain?

Induce Pain.... Apprehension Sign Load and Shift Test Relieve Pain..... Relocation Test

A 40 y.o. stay at home mom is diagnosed with a labral tear however, she has only slight limitation in ROM when compared to the healthy shoulder..... Is she more likely to undergo surgery or physical therapy as management of her condition?

Physical Therapy

A 19 y.o. football player is diagnosed with an anterior labral tear, and he has marked limitation in ROM.... Is he more likely to undergo surgery or physical therapy as management of her condition?

Surgery | Remember that PT is always a good option, but surgery is typically offered to athletes

What mechanical symptoms may a patient with a Superior Labral Anterior Posterior (SLAP) tear complain of?

Popping with rotation of the shoulder in abduction

What physical examination 'test' would be positive in a patient with a SLAP tear?

O'Brien's Test

A positive Jerk Test on PE would indicate a ________ (anterior/posterior/SLAP) tear?

Posterior

Hyperextension of the elbow and recurvatum of the knee would all be signs of laxity in what disorder?

Multidirectional Instability

A patient diagnosed with multi-directional instability should undergo PT for how long?

3-6 months

This disorder of the shoulder is described as progressive loss of active and passive glenohumeral ROM

Adhesive Capsulitis (Frozen Shoulder)

What are the THREE phases of adhesive capsulitis?

1. Inflammatory (PAIN) 2. Frozen (Loss of ROM) 3. Thawing (Return of motion)

Are patient with adhesive capsulitis likely to have permanent deficits?

Yes

T/F: Primary adhesive capsulitis is idiopathic

True

What are examples of causes of secondary adhesive capsulitis?

1. DM 2. Trauma 3. MI / CVA 4. Rheumatic Disorders

Although adhesive capsulitis is typically self limiting....... what treatment options are available?

1. NSAIDs 2. Corticosteroids (Injections vs PO) 3. PT 4. Surgery (Adhesion Lysis)

Would glenohumeral arthritis pain be worse in the morning or late in the day?

Later in the day

What may be seen on radiography studies in a patient with glenohumeral arthritis?

Joint space narrowing, osteophytes, cysts

What medications and in-office procedures can be done for treatment of glenohumeral arthritis?

NSAIDs | Corticosteroid Injection

What is the most common mechanism resulting in a proximal humerus fracture?

Fall onto an outstretched arm

When treating a proximal humerus fracture which is more common...... Non-operative or surgical repair?

Non-operative

A 25 y.o. male present s/p high speed MVA in which he was T-Boned on the driver's side. Luckily, he has no complaints other than severe left upper arm pain. On examination, there is significant swelling to the mid-upper left arm. What bony injury is most concerning given this type of direct blow mechanism?

Humeral Shaft Fracture

A 25 y.o. male present s/p high speed MVA in which he was T-Boned on the driver's side. Luckily, he has no complaints other than severe left upper arm pain. On examination, there is significant swelling to the mid-upper left arm. XR reveals a humeral shaft fracture. Does this type of fracture typically require surgery? What would be an indication of surgery in this type of fracture?

No (90-95%) Surgery would be indicated if...... ``` Open Fracture Neurovascular Injury Multiple Fractures Intra-articular Fx Very Poor Malalignment ```

A 59 y.o. female presents to your office with arm pain. She noted that while helping her son move she was lifting a box and heard a pop in her right shoulder and upper arm. On examination, there is bruising and swelling over the bicep. What physical examination finding would be consistent with bicep tendon rupture?

Pop Eye Deformity

A 59 y.o. female presents to your office with arm pain. She noted that while helping her son move she was lifting a box and heard a pop in her right shoulder and upper arm. If this patient noted she had a pain in the anterior shoulder for a few weeks prior to the incidence, what underlying tendon issue may she of had?

Bicep Tendonitis

How are proximal bicep tendon ruptures managed? Distal?

Proximal: Conservative Distal: Surgical Repair

What imaging study is utilized in evaluating bicep tendon ruptures?

MRI

A 45 y.o. male presents with lateral left elbow pain over the last 2 weeks. He has been a construction worker for 25 years and is an avid tennis player. He noted that the pain has interfered with his ability to work (ie: hammering). On examination, the pain is reproduced with resistance against wrist extension and supination. What is your suspected diagnosis? How would you treat this condition?

Lateral Epicondylitis ("Tennis Elbow") Treatment: NSAIDs Stretching Bracing

Does "Golfer's Elbow" involve the lateral or medial epicondyle?

Medial Epicondylitis

In a patient with medial epicondylitis (Golfer's Elbow) have pain with resisted wrist flexion or extension? Pronation or supination?

In medial epicondylitis patients will have pain with resisted wrist flexion and pronation

How is medial epicondylitis treated?

NSAIDs Stretching Bracing

Pain, swelling, and erythema over the olecranon process would be indicative of what condition?

Olecranon Bursitis

What are common causes of olecranon bursitis?

Trauma (Penetrating) Infection Gout Repetitive Motion

How is olecranon bursitis treated?

NSAIDs Ice Compression Sleeves Corticosteroid Injections

Elbow dislocations are commonly a result of _______ (high/low) speed trauma

High-Speed

How are elbow dislocations typically treated non-surgically?

Closed Reduction Splinting PT

A 3 y.o. female presents to the ED with her mother complaining of elbow pain. While the two of them were playing this morning she was "swinging her around by her arms when she heard a pop in her left elbow". The child cried at first but was easily consolable. However, since that time, she has not been moving or using that arm. On exam, the left arm is flexed and pronated and pain can be illicited near the radial head. She is neurovascularly intact distally. What is your suspected diagnosis and what imaging modality would be most diagnostic?

Nursemaid's Elbow XR

A 3 y.o. female presents to the ED with her mother complaining of elbow pain. While the two of them were playing this morning she was "swinging her around by her arms when she heard a pop in her left elbow". The child cried at first but was easily consolable. However, since that time, she has not been moving or using that arm. On exam, the left arm is flexed and pronated and pain can be illicited near the radial head. She is neurovascularly intact distally. How is this injury treated? Will this need splinted?

Closed Reduction No splint needed for the first injury, however, if this were to happen multiple time it may require casting

T/F: Compartment syndrome is NOT an orthopedic emergency

False It is

In the setting of trauma, fracture, or dislocation..... What THREE things always need to be checked PRIOR TO attempting reduction of a fracture or dislocation? (Its not ABCs)

Sensation Motor Function Pulses Distal to the injury

In the setting of trauma, fracture, or dislocation..... What THREE things always need to be checked AFTER reducing a fracture or dislocation?

Sensation Motor Function Pulses Distal to the injury

T/F: Open fracture are an orthopedic emergency

True

Should all fractures be referred to an orthopedic surgeon?

Yes

What are two risk factors for non-union healing of fractures?

Smoking | DM

What is the most common elbow fracture in children?

Supracondylar fractures

Are supracondylar fractures more likely a result of hyperextension of hyperflexion injuries?

Hyperextension

Supracondylar fractures are serious injuries as they have higher risks of neurovascular involvement . Which artery and nerve are involved in these fractures?

Median Nerve | Brachial Artery

A 55 y.o. male presents to the ED with right elbow pain following a fall onto an outstretched arm. On exam, there is ecchymosis and swelling over the lateral aspect of the elbow. The most concerning finding is lack of supination and pronation in that arm. What is you suspected diagnosis? A. Ulnar Fracture B. Supracondylar Fracture C. Radial Head Fracture D. Scaphoid Fracture

C. Radial Head Fracture Loss of supination and pronation is common in this type of injury in combination with lateral elbow pain following a trauma

When can radial head fractures be treated non-operatively?

Small Degrees of displacement or comminution | Less than 30 degrees of angulation with rotation intact

When treating a radial head fracture non-operatively..... The arm should be splinted at a _____ (90/45/180) degree angle. Are these patients allowed to lift during the healing process?

90 Degree Angle No, these need to be non-weight bearing

Which muscle is the likely culprit of deformity and displacement in an olecranon fracture?

Triceps

T/F: Olecranonn fractures are most commonly treated non-operatively

False These injuries most often require surgical fixation

This fracture is described as a fracture of the proximal ulnar and a dislocation of the radial head.

Monteggia Fracture

This fracture is described as a fracture of the radius and dislocation of the distal radioulnar joint. How are these treated?

Galleazzi Fracture These typically require surgical fixation (Always refer to orthopedic surgeon for these injuries)

When evaluating a "both bone fracture (radius and ulnar fracture)" there can often be significant swelling..... What is the most concerning complication from this injury?

Compartment Syndrome

Which is more likely to be treated surgically..... A radial and ulnar fracture in an adult A radial and ulnar fracture in a child

A radial and ulnar fracture in an adult (Remember: Less likely to preform and ORIF on a child as they are still growing, these injuries are treated with closed reduction and long arm casting)

A tear of which ligament in the wrist/hand would manifest on XR as a widening of the space between the scaphoid and lunate bones and possible the descending of the capitate bone into that space?

Scapholuniate Ligament

___________ is defined as inflammation of the synovial sheath surrounding a tendon

Tenosynovitis

A 46 y.o. female presents to your office with right thumb pain. She noted the pain has gradually onset over the last few days and is located more over the dorsal aspect of the thumb. She has worked as a secretary for 20+ years, and the pain is starting to interfere with her ability to work. On examination, there is swelling present over the dorsal thumb and significant pain is illicted with ROM particularly in extension. There is no evidence of atrophy of the thenar eminence and Tinel's Test is negative. What physical examination test would be positive to affirm your diagnosis of DeQuervain's Tenosynovitis?

Finkelstein's Test

What two muscle tendons are typically involved in DeQuarvain's Tenosynovitis?

Extensor pollicis brevis | Abductor pollicis longus

How is DeQuarvain's Tenosynovitis managed?

Splint Ice Rest NSAIDs (or injections)

When would surgical management of DeQuarvain's Tenosynovitis be warranted?

After 6 months of failed conservative management

A _____ _____ is the most common soft tissue mass of the hand or wirst and is described as a mucin filled cyst which communicates via a stalk with an adjacent joint or tendon sheath

Ganglion Cyst

Are ganglion cysts more commonly on the dorsal or volar aspect of the hand/wrist?

Dorsal

Which management option of ganglion cysts results in a lower recurrence?

Surgical Excision

How can ganglion cysts be managed non-operatively?

Splinting NSAIDs Aspiration

What is the most common compression neuropathy of the upper extremity?

Carpal Tunnel Syndrome

Which nerve is often effected in carpal tunnel syndrome?

Median Nerve

A 52 y.o. male presents with complaints of numbness in his right hand. He described a progressive numbness and tingling in his right hand over the last month. He localizes this sensation mainly in his thumb, index, and middle fingers. He has worked in computer science for 20 years now and the sensation has hindered his ability to work on the computer. In addition, he noted that he is right hand dominant and he has been dropping his pens more frequently. Where on physical examination would you expect to see atrophy?

Thenar Eminence of the Thumb

A 52 y.o. male presents with complaints of numbness in his right hand He described a progressive numbness and tingling in his right hand over the last month. He localizes this sensation mainly in his thumb, index, and middle fingers. He has worked in computer science for 20 years now and the sensation his hindered his ability to work on the computer. In addition, he noted that he is right hand and he has been dropping his pens more frequently. What TWO physical examination tests may confirm your suspected diagnosis of carpal tunnel?

Phalen's Test | Tinel's Sign

A 52 y.o. male presents with complaints of numbness in his right hand He described a progressive numbness and tingling in his right hand over the last month. He localizes this sensation mainly in his thumb, index, and middle fingers. He has worked in computer science for 20 years now and the sensation his hindered his ability to work on the computer. In addition, he noted that he is right hand and he has been dropping his pens more frequently. On examination you note atrophy of the thenar eminence and a positive Phalen's Test. What would you recommend as initial treatment of this condition? What surgical release of what ligament could be recommended if initial treatment fails?

Splinting (especially at night) NSAIDs Activity Modification Surgical release of the transverse carpal ligament

What is a major risk factor (other than falling) for fracture in the elderly?

Osteoporosis

Make sure the patient is neurovascularly intact distal to the injury

A 14 y.o. male presents to the ED complaining of left wrist pain following a fall during a basketball game. He was tripped during the game and tried to brace himself with his left hand. He has since noticed significant pain and swelling to the wrist. On examination, there is a gross deformity of the wrist with swelling present. You spare the patient palpation as it is likely tender. He is neurovascularly intact distally. You order an XR as you suspect fracture, and it shows a fracture of the distal radius with dorsal angulation. This can be classified as what type of fracture?

Colles Fracture

A 14 y.o. male presents to the ED complaining of left wrist pain following a fall during a basketball game. He was tripped during the game and tried to brace himself with his left hand. He has since noticed significant pain and swelling to the wrist. On examination, there is a gross deformity of the wrist with swelling present. You spare the patient palpation as it is likely tender. He is neurovascularly intact distally. XR is consistent with a Colles Fracture. What would be your recommended management of this patient?

Closed Reduction Sugar-Tong Splint (6-8 weeks) Referral for orthopedic evaluation

What is the most common carpal bone fracture?

Scaphoid fracture

Tenderness over the 'anatomical snuffbox' would be indicative of a fracture of what?

Scaphoid

If you were concerned over an occult scaphoid fracture that was not detected on XR..... What imaging modality could you use?

MRI

What is the most concerning complication of a scaphoid fracture given it's poor blood supply?

Avascular Necrosis

Which finger(s) are most commonly affected in trigger finger?

Thumb > MF > RF > IF > SF

Stenosing Tenosynovitis is often described what?

Trigger Finger

On physical examination of a patient with trigger finger..... You may see a nodule and tenderness over the ___ pulley.

How is Trigger Finger managed?

NSAIDs Stretching Possible Surgical Release

________ _________ is a fibroproliferative disease of the palmar fascia in which painless cords or nodules form on the plamar aspect of the hand.

Dupuytren's Contracture

Is Dupuytren's Contracture typically flexion or extension?

Flexion

Are males or females more likely to develop Dupuytren's Contracutres? Are they more likely to be unilateral or bilateral?

Males Bilateral

What are the TWO most commonly dislocated joints in the hand?

DIP | PIP

How should finger dislocations typically be managed? When would an urgent referral be indicated?

Splint Refer Urgent referral is the dislocation is unstable or irreducible

A 'Boxer's Fracture' is a fracture of what metacarpal?

Neck of the 5th metacarpal

A 18 y.o. male presents to the ED with right hand pain. He noted that his girlfriend dumped him and in a fit of anger punched a wall. Since that time he has noticed pain and swelling to the lateral and dorsal aspects of his hand. On exam, his lateral right hand is marked swollen and you can no longer clearly see his 5th MCP joint. What is you suspected diagnosis and what imaging modality would be most diagnostic? How would you manage this condition?

Boxer's Fracture XR Splint and follow to monitor for displacement

Laxity with valgus stressing of the thumb would indicate an injury to what ligament of the hand?

Ulnar Collateral Ligament

An MRI of a thumb with a ulnar collateral ligament tear would have what type of lesion on it?

Stener Lesion

How would a partial UCL tear in the thumb be managed? Complete Tear?

Partial: Thumb Spica (4-6 weeks) Complete: Thumb Spica and Surgical Repair

How should hand tendon injuries with open wounds present be managed?

Irrigate wound Approximate edges with sutures Splint REFER

Why is it crucial to refer hand tendon injuries (ie: ruptures, lacerations) to an orthopedic hand surgeon?

These injuries can be permanent and lead to disability if not treated promptly

in Mallet finger, are the extensor or flexor tendons effected?

Extensor Tendons

How is Mallet Finger managed?

CONTINUOUS splint for 6-8 weeks

A 81 y.o. female presents to your office for evaluation of right thumb pain. She noted that the pain is mainly localized at the base and has been progressing over the last few months. It started to become concerning recently as she was having trouble even turning her house keys or buttoning her shirts. She denied any trauma prior to the onset of the pain. On examination you note tenderness to the base of the dorsal thumb, mild swelling, and pain illicted with the grind test. You wisely order an XR to evaluate for what chronic change in the thumb which is highly prevelant in elderly women?

Carpometacarpal Joint Arthritis

A 81 y.o. female presents to your office for evaluation of right thumb pain. She noted that the pain is mainly localized at the base and has been progressing over the last few months. It started to become concerning recently as she was having trouble even turning her house keys or buttoning her shirts. She denied any trauma prior to the onset of the pain. On examination you note tenderness to the base of the dorsal thumb, mild swelling, and pain illicted with the grind test. You wisely order an XR and suspect to see arthritic changes at what joint?

Trapeziometacarpal Joint

A 81 y.o. female presents to your office for evaluation of right thumb pain. She noted that the pain is mainly localized at the base and has been progressing over the last few months. It started to become concerning recently as she was having trouble even turning her house keys or buttoning her shirts. She denied any trauma prior to the onset of the pain. On examination you note tenderness to the base of the dorsal thumb, mild swelling, and pain illicted with the grind test. XR confirms Carpometacarpal Joint Arthritis. How do you plan to manage this condition?

NSAIDs vs Corticosteroid Injections Thumb Spica Splint PT

What mechanisms or injuries could lead to an infection in the hand?

Skin Trauma (Scratching, Penetrating, Puncture, etc...) Animal Bite Ingorwn Nail/Hair

How is a cellulitis of the hand initially managed?

ABx

If a palpable abscess is felt in the hand, what procedure is indicated? Any purulence collected should be sent for what?

Incision and Drainage (I&D) CULTURE IT!

Patients presenting with any type of wound (ie: cut on a knife, piece of metal, nail at a construction site) should be asked about the status of what vaccination?

Tetanus If out of date....up date it at time of presentation

Upper Extremity Flashcards

(130 cards)