Flashcards in Upper Extremity Disorders Deck (79):
4 articulations of the shoulder
1. GH (2/3 of motion)
2. Scapulothoracic (1/3 of motion)
Shoulder stability is dependent on:
Capsule, ligaments, rotator cuff muscles
Which rotator cuff muscle is most susceptible to injury?
Which rotator cuff muscle acts as an internal rotator?
Which rotator cuff muscle acts as an external rotator?
What are the intrinsic muscles of the shoulder?
Rotator cuff muscles (SITS)
What are the extrinsic muscles of the shoulder?
Is the biceps muscle an intrinsic or extrinsic muscle of the shoulder?
-Intrinsic function: stabilize GH joint
-Extrinsic function: flex elbow
Patients younger than 40 w/GH instability are more likely due to:
Patients over 40 w/GH instability are more likely due to:
AC and GH OA
Rotator cuff tear
Anterior pain along the shoulder joint line suggests:
Long head biceps tendinitis
Lateral pain over deltoid area suggests:
Rotator cuff tendinitis/tear
Posterior pain or referral to scapular suggests:
Tendinopathy of ERs (infraspinatus and teres minor)
Focal pain on top of shoulder suggests:
AC joint involvement
Major peripheral nerves of the shoulder that can be injured:
Long thoracic (C5-8)
Spinal accessory (C3-4)
What is the MC injured nerve of the shoulder?
What shoulder injury MC affects axillary nerve?
What nerve is usually injured due to poorly fitting backpack?
Spinal accessory nerve
Describe rotator cuff tendinitis
-Thickening of tendon w/inflammation of overlying bursa
-Results in edema and sometimes micro tears
-Can occur at any age
Clinical presentation of rotator cuff tendinitis
-Pain in shoulder radiates to upper arm (but NOT past elbow)
-Worse w/overhead activity
Treatment of rotator cuff tendinitis
-Sling is NOT encouraged as it may cause more stiffness
Describe calcific tendinitis of shoulder
-Presents similar to rotator cuff tendinitis but usually more pain w/ROM
-X ray shows Ca deposit
Treatment of calcific tendinitis of shoulder
What is the MC cause of shoulder pain?
Describe impingement syndrome
-Compression of structures around GH joint that occurs w/shoulder elevation
-Can affect SA bursa, biceps tendon (long head), rotator cuff
Stages of impingement syndrome
Stage 1: edema and hemorrhage (under 25 yo pts)
Stage 2: fibrosis and tendinitis (25-40 yo pts)
Stage 3: MC, rotator cuff tear, pts over 40 yo
What is the MC stage of impingement syndrome?
Stage 3: rotator cuff tear, patients over 40, have had at least 1 occurrence of Stage 1 or Stage 2
Definitive treatment of impingement syndrome
Surgical SA decompression (it opens the space and gives direct visualization to rotator cuff)
2 types of rotator cuff tears
1. Acute traumatic
2. Chronic degenerative
Describe acute traumatic rotator cuff tear
-FOOSH or grabbing on while falling
-Acute pain referred to deltoid
-Significant pain when sleeping on affected side
Describe chronic degenerative rotator cuff tear
-Similar to tendinitis and impingement syndrome
-Wear on tendon gradually tears through
What is the gold standard for diagnosis of acute rotator cuff tears?
MRI (may need gadolinium)
Definitive treatment of degenerative rotator cuff tear?
What is the shoulder labrum?
-Cartilaginous rim around glenoid
-Provides additional stability while not compromising mobility
What is a Bankart lesion?
-Torn labrum (stripped away from bone)
-Anterior dislocation can cause this
-Does NOT heal on its own
What is the most obvious finding on exam of a Bankart lesion?
Positive apprehension test and relocation sign
Describe SLAP tear
-Superior labral tear from anterior to posterior
-Symptoms similar to RC tear and impingement syndrome
-Weakness against resistance on affected side w/their palms up and arms extended from body at 90 degrees
Definitive treatment of Bankart lesions and SLAP tears?
Arthroscopic surgical repair followed by 2-4 weeks of sling and swathe immobilization and pendulum exercises
Bursitis in the shoulder can lead to:
Impingement syndrome (if chronic)
Define frozen shoulder
-Gradual development of global limitation of active and passive shoulder motion
-Absent radiographic findings (other than osteopenia)
How does frozen shoulder develop?
Commonly after shoulder injury and extended immobilization
Who is affected by frozen shoulder?
Over 40 yo
Pathophys of frozen shoulder
-Thickening and contraction of GH joint capsule and collagenous tissue surrounding joint
-Results in reduced joint volume
Clinical presentation of frozen shoulder
-Initial painful phase, worse at night and increasing stiffness lasting 2-9 months
-Intermediate phase w/less pain 4-12 months
-Recovery phase w/gradual return of ROM that takes 5-24 months
Treatment of frozen shoulder
-Very slow process
-Some cases, rupture of adhesions w/manipulation under anesthesia
-Intra-articular steroid injections
What is Yergason's test?
-To determine biceps tendinitis
-Pain is reproduced w/elbow flexed to 90 degrees and forearm supinated against resistance
Describe biceps tendon rupture
-MC males over 50 yo
-Many have h/o chronic tendinitis
-Bicep looks like Popeye muscle
-Permanent injury w/some loss of strength
Treatment of biceps tendon rupture
-Nonsurgical is risky bc restoring arm function w/later surgery may not be possible
-Tendon should be repaired during first 2-3 wks after injury (after this the tendon and muscle begin to scar/shorten)
Describe osteolysis of AC joint
-MC seen in weightlifters
-Point tenderness at AC joint
Definitive treatment of osteolysis of AC joint
Distal clavicle resection (done open or arthroscopic)
What diagnoses osteolysis of AC joint?
Injection of lidocaine and steroid directly into AC joint (resolves pain)
Describe lateral epicondylitis
-Overuse injury of extensor tendons
-MC in dominant hand
Describe medial epicondylitis
-Less common than tennis elbow
Describe olecranon bursitis
-Inflammation of subcutaneous synovial lined sac of the bursa overlying the acromial process
-Swollen, boggy, sometimes tender olecranon bursa
Describe septic olecranon bursitis
-Infected olecranon bursa
-MC cause is disruption of skin
-MC organism is S. aureus/MRSA
-Red, hot, swollen, tender
Treatment of septic olecranon bursitis
-Abx with Staph/MRSA coverage
-Keflex, Doxy, Trimetoprim, Sulfametoxazole
Describe Boutonniere deformity
-Injury to tendon that prevents full extension at PIP joint
-MOI forceful blow to flexed finger or laceration
Describe Mallet finger
-Disruption of extensor tendon at DIP joint
-MOI: ball or other object strikes tip of finger or thumb and forcibly bends it
Describe swan neck deformity
-MC cause is RA
MC cause of swan neck deformity?
Describe trigger finger
-Flexor tendon becomes thickened and nodules form at A1 pulley
-Tendon becomes stuck and has to be pulled into extension
-Cause is unknown
-MC in women, 40-60 yo, DM, RA, 4th finger
Describe Dupuytren's contracture
-Fixed flexion contracture of hand
-Caused by nodular thickening of palmar fascial cords
-MC in 4th and 5th fingers
-MC in males
-Bilateral in almost 50%
Definitive treatment of Dupuytren's contracture
MC joints of hand and wrist affected by OA
Who is affected by OA of hand and wrist?
Males more if under 45 yo
Females more if over 45 yo
Heberden's nodes occur at:
Bouchard's nodes occur at:
Presentation of first CMC joint OA
-Post menopausal women
-Nocturnal pain and weakness
-Aggravated by pinch/grasp
Are steroid injections more helpful for OA of hand/wrist or of 1st CMC joint?
1st CMC joint
Describe DeQuervain's tendinitis
-1st dorsal compartment tenosynovitis (tendon sheath)
-Overuse of thumb
-Pain is in anatomical snuffbox
-Finklestein's test positive
Describe carpal tunnel syndrome
-Median nerve compression at carpal ligament
-Increased incidence in DM, thyroid disease, pregnancy
-Positive Phalen's or Tinel's
Gold standard for diagnosis of carpal tunnel syndrome?
Definitive treatment of carpal tunnel syndrome?
Carpal tunnel release
Describe cubital tunnel syndrome
-Ulnar nerve compression at elbow in ulnar groove
-Pain is worse w/elbow flexed
-Atrophy of intrinsic muscles
-Positive Tinel's at ulnar groove
-Soft tissue infection localized to proximal or lateral nail fold
-Usually w/fluctuant mass or visible pus
-S. aureus/MRSA MC
Definitive treatment of paronychia
-I&D with digital block (culture and sensitivities)
-Abx for 5 days
-Closed space infection of pulp of finger
-S. aureus MC
-Wooden splinters and minor cuts MC cause
-Pack loosely w/gauze and change every 2-3 days
-Abx to cover S Aureus/MRSA
Describe herpetic whitlow
-Digital herpes (viral)
-Common in children, HC workers in dentistry
-Self limiting (2-3 wks)