Upper Extremity Disorders Part 2 Flashcards
(109 cards)
1
Q
imaging for elbow
A
- Standard x-ray views - AP & lateral
- Additional views:
- Oblique (Radiocapitellar) 45° view - Improved radial head visualization
2
Q
interpretation of lateral view of elbow imaging
A
- The anterior humeral line (1-2) should bisect middle third of capitellum.
- The radiocapitellar line (drawn through center of radius, 3-4) should also pass through the center of the capitellum.
- Disruption of these relationships may indicate fracture.
3
Q
components of elbow assessment
A
-
ROM
- Flexion 0-150°
- Hyperextension 10-15° (usually kids only)
- Supination/Pronation 80° -
muscle strength
- Flexion and supination - Bicep, C5-C6, musculocutaneous nerve
- Extension - Tricep, C7-C8
- Pronation - Pronator teres muscles, median nerve, C6-C7 -
ligament testing
- valgus stress test
- varus stress test
4
Q
what is the valgus stress test in elbow assessment
A
- Tests the stability of the medial ligamentous structures, primarily the ulnar collateral ligament
- Hold elbow in 20° flexion with forearm in supination; apply pressure on lateral side of the elbow, attempting to open medial joint line
5
Q
how to perform varus stress test in elbow assessment?
A
- Tests the stability of the lateral collateral ligament and lateral capsule
- Hold the elbow in 20° flexion with the forearm in supination and apply pressure on the medial side of the elbow, attempting to open the lateral joint line
6
Q
3 fracture patterns of distal humeral fx - which are MC in general and MC in children?
A
- Supracondylar (MC in children) - Type A
- Epicondylar (medial or lateral) - Type B
- Intercondylar - Type C (MC)
7
Q
complications of distal humeral fx
A
- Intra-articular or comminuted fractures
- Nerve injury - Ulnar nerve; Radial
8
Q
presentation of ulnar and radial nerve injury from distal humeral fx
A
- Ulnar nerve - Sensory changes; Flexion/adduction wrist, 4th and 5th DIP joint flexion, finger abduction
- Radial - Sensory; wrist extension
9
Q
presentation of distal humeral fx?
what to check in Supracondylar Fx and epicondyle fx?
A
- Pain, swelling, tenderness, ecchymosis and crepitus
- Elbow ROM limited
- Shortening of arm with displaced shaft fx
- Skin, joints/bones above and below, NV status
- Supracondylar Fx: radial artery, median nerve
- Epicondyle Fx: ulnar nerve (medial), radial nerve (lateral)
10
Q
imaging for distal humeral fx?
findings? MC in who?
A
-
AP and lateral elbow X-ray
- Assess fracture details
- Look for fat pad “sail sign” - Indicates intra-articular bleeding; May be evidence of occult fracture; MC seen in kids
11
Q
management for supracondylar distal humeral fx
A
- Isolated w/o displacement or angulation - Long arm cast/splint with elbow flexed at 90°
- Displaced, angulated, or NV compromise: ORIF
12
Q
management for epicondylar distal humeral fx
A
-
Isolated, minimally displaced (< 2 mm): Long arm cast/splint with elbow at 90 °
- Medial condyle fx - forearm pronate
- Lateral condyle fx - forearm supinate - Moderate displacement (2-4 mm): Percutaneous pinning or ORIF
- Severe displacement: ORIF
13
Q
MC MOI of olecranon fx?
2nd MC?
A
- fall on a semi-flexed supinated forearm (avulsion)
- 2nd MC: direct trauma
14
Q
Presentation of olecranon fx?
A
- Pain, tenderness, swelling and ecchymosis overlying olecranon process
- Limited ROM of elbow
- Deformity if associated elbow dislocation
- Assess distal NV status and overlying skin
15
Q
which nerve is MC affected if NV status is compromised in olecranon fx?
A
ulnar nerve
16
Q
imaging for olecranon fx
A
- AP and lateral elbow
- Radiocapitellar view - If unclear or complicated presentation
17
Q
management for nondisplaced olecranon fx
A
< 1-2 mm displacement
- Posterior long arm splint with elbow in any degree of flexion, forearm in neutral position
- hand/finger ROM/strength: rubber ball x 5 min daily
- Repeat x-ray in 7-10 days to ensure alignment is intact
- Cast/splint removed after 2-3 wks
- Start gentle ROM therapy
- Consider PT referral (improves outcomes)
18
Q
management for displaced (open & closed) olecranon fx
A
- Closed fx: splint and refer for ORIF
- Open fx: admit for IV abx and consult ortho
19
Q
Contraindications for olecranon fx surgery may be present in who?
alt management?
A
- elderly or multiple comorbid conditions
- Tx: sling and start ROM as pain allows
20
Q
MOI of radial head/neck fx
A
FOOSH resulting in compression of radial head into the capitellum
21
Q
Most common fracture of the elbow?
A
Radial Head/Neck Fracture
22
Q
classification for Radial Head/Neck Fracture?
A
Mason Classification
- Type I - < 2 mm displacement
- Type II - displaced > 2 mm
- Type III - comminuted
- Type IV - radial head fracture with associated elbow dislocation
23
Q
- Pain and tenderness along the lateral aspect of elbow (overlying the radial head)
- Limited ROM
- Related to pain or joint effusion
- Painful pronation/supination - +/- local swelling/ecchymosis
dx?
A
Radial Head/Neck Fracture
24
Q
imaging for Radial Head/Neck Fracture
A
-
AP and lateral elbow
- Fracture line
- Fat pad sign -
Capitellar (oblique) view
- If unable to appreciate fracture on standard views
25
management for type 1 radial head/neck fx
1. **Sling** +/- posterior splint → splint should be removed after 1-2 days
1. **AROM after 24-48 hours**
- Full extension, flexion
- Pronation and supination with elbow flexed at 90°
1. F/u with **ortho within 1 week**
1. Aspiration if hemarthrosis is present to allow early ROM
26
Type II - III radial head/neck fx management
1. Sling and splint with ortho evaluation in 2-3 days to discuss consideration of ORIF
1. Ortho can assess for mechanical block
27
management for type IV radial head/neck fx
Immediate consult for reduction and ORIF
28
what is Radial Head Subluxation?
MC in what age group?
* Subluxation (partial dislocation) of radial head through annular ligament due to laxity
* Kids < 5 y/o
AKA: “**Nursemaid’s elbow**”
29
* MOI: Pulling on a **pronated forearm while the elbow is extended**
* Hx of mechanism followed by crying which subsides quickly
* Arm is held **semi-flexed, adducted, and pronated**
* ROM is refused - Resistance noted with attempted supination
* Tender over radial head
* No swelling or ecchymosis
dx? imaging?
radial head subluxation
imaging not needed unless sus of other injury (X-ray)
30
management for radial head subluxation
1. **Reduction**
- Premedicate with Tylenol or Motrin
- 2 techniques: **Supination-flexion; Hyperpronation**
2. Immediate **re-assessment of NV status**
3. After 15-30 minutes
- no improvement (full flexion and supination): reattempt reduction
- 3-4 attempts would be acceptable
4. _Reduction less successful if 1-2 days after injury_
5. Failed reduction
- Order radiographs
- Splint (posterior long-arm) and refer to ortho
6. Successful reduction
- Tylenol/Motrin prn
- +/- sling
- Parent education
31
how to perform supination-flexion reduction?
1. Hold the elbow with the your thumb overlying the radial head
1. Quickly supinate fully
1. Followed by complete flexion
32
how to perform hyperpronation reduction?
1. Hold the elbow with the your thumb overlying the radial head
1. Hyperpronate the forearm
1. Followed by complete extension then flexion
33
EBM states that this technique is often more effective the first time and may be less painful for radial head subluxation
hyperpronation reduction technique
34
which epicondylitis is MC
1. **Lateral**: wrist extensors (aka tennis elbow) - MC
1. Medial: wrist flexors (aka golfers elbow)
35
MOI of epicondylitis?
MC in what age group?
* **Chronic repetitive overuse** resulting in micro-trauma at tendon insertion; Acute strain due to excessive loading
* MC between **30-50**
36
1. Pain with wrist extension and gripping
- Shaking hands, using computer mouse, use of screwdriver, back-handed tennis swing
1. **Point tenderness 1 cm distal to epicondyle**
1. **Pain with ROM against resistance** (elbow extended) - _wrist extension and supination_
dx?
Lateral (Tennis Elbow) Epicondylitis
37
1. Pain with arm pronation and wrist flexion, grip pain/weakness
- Golf swing, overhead throwing, bowling
1. **Point tenderness 1 cm distal to epicondyle**
1. **Pain with ROM against resistance** (elbow extended) - _wrist flexion and pronation_
dx?
Medial (Golfer’s Elbow) Epicondylitis
38
Dx and Tx for epicondylitis
1. Normal AP and lateral elbow (not needed for dx)
1. Activity modification, NSAIDs (topical or oral), Ice after use
1. Refer to PT if failure of conservative tx - PT after initial pain subsides
1. Bracing - **Counterforce brace**
1. Steroid injection x 3 max
1. Refer to ortho if symptoms persist for 6 months of conservative therapy
39
Causes of olecranon bursitis
1. **Trauma** - Fall, direct blow to elbow
1. **Inflammation**
- Excessive leaning on the elbow
- systemic inflammatory conditions - RA, gout etc.
1. **Infection** - Septic bursitis - MC _staph and strep_
40
1. Gradual or sudden swelling of the bursa
- Up to 6 cm in diameter
- As the swelling subsides small lumps of scar tissue will remain
2. **+/- pain, tenderness, limited ROM**
- More so in trauma and infectious etiologies
- Chronic recurrent swelling is less tender
3. **Redness and warmth in acute bursitis**
olecranon bursitis
41
diagnostics for olecranon bursitis (2)
1. **Aspiration** - for large, symptomatic bursa - CBC, Gram stain, C&S, Crystals
2. **AP and lateral elbow x-ray** - if hx of trauma
42
management for mild olecranon bursitis w/o sepsis
**Activity modification and NSAIDs**
Use of an elbow pad, compression during acute phase
43
* management for significant swelling olecranon bursitis w/o sepsis?
* management if swelling persists?
**Aspirate, apply compression bandage, and f/u in 2-7 days**
1. If fluid returns and cx are negative **repeat aspiration** and re-cx
- If cx remain negative but **swelling persists**, aspiration and **injection of 1 mL of corticosteroid** into the bursal sac
44
management for Mild, with no immunosuppression, septic olecranon bursitis
1. Oral **Bactrim**
- Alt. cephalexin
2. Abx therapy tailored to culture and sensitivity once available
45
management for septic olecranon bursitis with severe presentation/immunocomp
1. **IV vancomycin**
- Add **Cipro** or **pip-taz** if associated with **trauma**
2. Abx therapy tailored to culture and sensitivity once available
46
presentation of severe olecranon bursitis (septic)
1. Systemic toxicity (fever, hypotension, tachycardia)
1. Rapid progression or progression 48 hours after abx
1. Unable to tolerate oral therapy
1. Close indwelling medical device - ex: prosthetic joint or vascular graft
47
MOI of forearm fx
* Direct blow
* FOOSH
48
**Radial** midshaft fracture associated with instability of the distal radioulnar joint (DRUJ)
which type of complicated forearm fx?
Galeazzi fracture
49
Fracture of the proximal third of the **ulnar** shaft associated with dislocation of the radial head due to instability of the proximal radioulnar joint (PRUJ)
which type of complicated forearm fx?
Monteggia fracture
50
indications for **emergent** ( < 1 hr) ortho referral for forearm
1. arterial compromise
2. open fx
51
Indications for urgent ( < 24 hr) ortho referral for forearm fx in adults
1. ulnar shaft fx with < 50% apposition or >10 degrees angulation
2. **any** DRUJ or PRUJ instability
3. peripheral nerve injury
4. displacement
52
indications for priority (24-72 hr) ortho referral for forearm fx in adults
1. isolated radial shaft fx with any displacement
2. both-bones fx, even with min or no displacement
3. isolated proximal 3rd ulna fx
53
management for Simple, isolated, fx of the ulnar shaft (middle-distal ⅓)
*_< 50% displacement, < 10% angulation_ before or after closed reduction and _no joint involvement_*
1. **Long-arm posterior splint**
- Elbow at 90 degrees
- Forearm in neutral position
- Slight wrist extension
2. After 1-3 wks - **functional forearm brace** x 4-6 wks
3. **F/u x-rays** to ensure alignment **at 1 wk and then q4wk** until complete healing has occurred (usually 8 wks)
54
management with **Double sugar tong splint** and refer these presentations to **Ortho**: (3)
1. Isolated radial fractures
2. Combined radius-ulna fracture
3. Galeazzi or Monteggia fracture
55
MC MOI of wrist fx
FOOSH
56
common types of wrist fx
which is MC?
1. **Colles fx (MC)** - the distal radius fracture fragment is tilted **dorsally**
1. **Smith’s fx** - the distal radial fragment is tilted **volarly**
57
presentation of wrist fxs?
diagnostics?
1. Acute pain, tenderness, swelling
1. Deformity of the wrist
- **Colles** - “dinner fork” deformity (dorsal)
- **Smith’s** - “garden spade” deformity (volar)
1. diagnostics - wrist XR series
58
management for _nondisplaced or minimally displaced and non-articular_ **wrist fx**
1. **Sugar tong splint / short arm cast** x 2-3 wks
- Casts should not be placed until _72 hours after injury_
2. AP and lateral **radiographs** each week x 2 wks
59
management for _Displaced and open_ **wrist fractures**
ORIF
60
Most common carpal fx?
MC in what pt demographic?
scaphoid fx
young men
61
for scaphoid, blood supply enters where?
at the distal ⅓ of the bone
62
complications of scaphoid fx
1. High incidence of delayed diagnosis
1. Non-union
1. Avascular necrosis
63
1. Wrist pain/swelling along radial aspect
1. Tenderness along the **anatomical snuff box**
1. Grip and ROM may be painful/weak/limited
scaphoid fx
64
diagnostics for scaphoid fx
1. **Wrist series + _Scaphoid (navicular) view_**
- PA view with the wrist in ulnar deviation
1. CT/MRI if x-rays remain negative and suspicion is high
65
management for _Nondisplaced_ **scaphoid fx** or _negative x-rays_
1. Thumb spica splint/cast x 6 wks
1. Refer to ortho
1. **Repeat x-rays** in 7-14 d if initially negative
- If negative and tenderness persists → CT/MRI
66
management for displaced scaphoid fx
1. ORIF
1. Percutaneous pin placement
67
Compression of which nerve that causes carpal tunnel syndrome
median
68
RF for carpal tunnel syndrome
1. Repetitive wrist movements
1. Wrist injury
1. Pregnancy
1. Sedentary lifestyle
1. Familial (idiopathic)
1. Multiple systemic conditions
69
1. Burning, tingling pain over the median nerve distribution of the hand
- Exacerbated by activity and at night
1. Aching pain radiating to elbow and shoulder
1. Physical Exam
- **Tinel’s and Phalen’s** signs
- **Carpal compression** test
- The **hand elevation test**
- Grip weakness
- Thenar atrophy (late)
dx?
w/u?
management
* carpal tunnel syndrome
* EMG/NCS
* Activity modification; Cock-up wrist splint; Corticosteroid injection; Refer for to ortho for carpal tunnel release - Failure of >3 m of conservative therapy; Objective neuro findings / thenar muscle atrophy
70
metacarpal fx are MC in what pt demographic?
adults
71
Mc fx in the hand is?
**Boxer's fracture**: Fracture of 4th and/or 5th metacarpal that results from a closed fist striking an object
72
phalangeal fx are MC in what pt demographic? involving which structure?
children - Involving the physis of the 5th phalange
73
MC phalangeal fx in adults?
The distal phalanx is the most commonly injured
74
presentation of metacarpal/phalangeal fx?
what type of fx is MC malrotated?
1. History of trauma
1. Local tenderness, swelling, deformity and decreased ROM
- Boxer’s fracture are most likely to be **malrotated**
1. Assess distal NV status
75
diagnostics for metacarpal/phalangeal fx?
XR hand series
76
management for metacarpal neck fx w/ >30 angulation?
**reduction**
open or closed reduction followe by splint/casting
77
management for metacarpal neck fx w/ < 30 angulation?
**splint** x 2-3 wks
* **4 / 5th** metacarpal = **Ulnar Gutter Splint**
* **2nd and 3rd** metacarpal = **Radial Gutter Splint**
78
management for Non-displaced fractures of the 2-5th metacarpal/phalangeal shaft
**Splint** for 3-4 weeks
* Metacarpal - gutter splint
* Phalangeal fracture - buddy tape or aluminum splint
79
management for Non-displaced 1st metacarpal/phalangeal fx
Thumb-spica splint, wrist in 30 degrees of extension
80
management for Non-displaced/non-articular 1st metacarpal base
Thumb spica splint/cast x 4 wks
81
management for Displaced/angulated metacarpal/phalangeal shaft fracture or intra-articular fractures
* Refer/consult ortho for further evaluation
* Closed vs open reduction and fixation
82
cause/MOI of gamekeeper's thumb
* Rupture of the **ulnar collateral ligament** of the 1st MCP joint
* Forced radial abduction
83
presentation of gamekeeper's thumb
1. Pain, swelling and tenderness along the medial 1st MCP joint
1. Weak pincer function
1. **Stress testing** after local anesthesia
84
diagnostics and tx for gamekeeper's thumb
* 1st phalange finger series
* Thumb spica splint; Refer to ortho for surgical repair
85
cause/MOI of mallet finger
* A rupture, laceration, or avulsion of the **extensor tendon** at the distal phalanx
* Hyperflexion of DIP
86
presentation of mallet finger
* DIP is flexed at 40° with the inability to actively extend
* **PROM is intact**
* Mild tenderness over dorsal DIP
* May be associated with an **avulsion fx** of the distal phalanx
87
diagnostics and tx for mallet finger?
How long?
complication if not tx properly?
1. finger series - r/o avulsion fx
2. finger splint
- DIP in full extension x **4-8wks**
- **cannot be removed**
3. _swan neck deformity_ - hyperextension of PIP w/ flexion of DIP
88
cause/MOI of boutonniere deformity
* Rupture of the central slip of the extensor tendon where it inserts on the middle phalanx
* Forced flexion of the PIP
89
1. **Deformity**: Finger is held partially flexed at the PIP and extended or hyperextended at the DIP
- May not be as noticeable due to swelling
2. Swelling, pain, point tenderness along the dorsal PIP
3. Limited ROM - **Inability to fully extend the PIP** - remains flexed at 30°
dx?
w/u?
tx?
When to refer?
Boutonniere Deformity
1. Finger series to r/o avulsion fx
2. Splint PIP in extension leaving DIP free x 4-8 wks; Refer to ortho if: If conservative therapy fails, Associated irreducible PIP dislocation, or Associated open fx
90
Inflammation of the tendon sheath covering the extensor/abductor tendons of the thumb
Overuse syndrome
dx?
De Quervain Tenosynovitis
91
1. **Aching pain and point tenderness** along the radial aspect of the wrist with use
1. Pain may radiate up arm
1. Thickened 1st dorsal compartment, creating a prominence at the radial styloid
1. **Finkelstein test is diagnostic** - Ulnar deviation of an adducted thumb reproduces pain
dx?
tx?
**De Quervain Tenosynovitis**
1. Thumb spica splint
1. Activity modification
1. NSAID’s
1. Refer to ortho if conservative therapy fails
- Corticosteroid injections into tendon sheath
- Surgical release of the first dorsal compartment
92
* A fluid-filled swelling overlying a joint or **tendon sheath** - Filled with clear, gelatinous, sticky, or mucoid fluid
* MC location - **dorsal** aspect of **wrist**
* MC in females ages 10-40
* Thought to occur as a result of mucoid degeneration of periarticular structures
dx?
Ganglion Cyst
93
Localized intermittent pain/tenderness
Cyst is firm, **smooth**, rounded, **rubbery**
May fluctuate in size over time
**Transillumination** will help differentiate cyst from solid lesion
dx?
w/u?
management?
Ganglion Cyst
1.**X-ray** - R/o bony pathology; **US/MRI** if atypical presentation
2. **Observation** - _MC spontaneously regress_; **Aspiration** +/- injection of a corticosteroid; **Surgical** removal
94
An idiopathic dysfunction of the flexor tendon of the finger as is glides through the tendon sheath
Often due to a discrepancy in the size of the tendon and is sheath
dx?
which fingers are MC affected?
trigger finger
3rd and 4th
95
1. **Catching, snapping or locking** of the involved finger(s)
- Often worse upon awakening
- More than one finger may be affected
2. Associated with pain and dysfunction
3. **Painful nodule on the palm**
dx?
management?
**trigger finger**
1. **NSAIDs, +/- corticosteroid injection** into the tendon sheath
- If persist: 2nd injection in 3-4 wks
2. Failure of conservative therapy (including two injections) → **surgical release**
96
Patients with what other condition are at increased risk for tendon rupture and should only have one corticosteroid injection when treating Trigger finger
RA
97
* A progressive **fibrosis of the palmar fascia**
* MC - **men > 50 yrs old**
dx?
which structure is MC affected?
* **dupuytren contracture**
* 4th phalange
98
RF for Dupuytren Contracture
1. Epilepsy
1. DM
1. pulmonary disease
1. alcoholism
1. smoking
1. repetitive vibrational trauma
99
* One or more **painless nodules near the distal palmar crease**
* The nodules gradually thicken leading to a **cord** that contracts
* ROM - Flexion is normal, but **extension is limited**
dx?
w/u?
tx?
* Dupuytren Contracture
* clinical dx
* Management:
1. **Night splinting** - _not curative_, but may slow the progression
1. **Surgery release**
- Indicated if 30° fixed flexion of the MCP
- Involves excising thickened soft-tissue bands and release of joint contractures
100
MOI of brachial plexus syndrome
1. **Traction force** - the shoulder is forcefully depressed & the head / neck are tilted toward the opposite side
- Damages C5, C6, and C7 roots
2. **Direct blow to the top of the shoulder**
- Damages C5, C6, and C7 roots
3. **Stretching of the plexus when the arm is abducted forcefully**
- Grabbing something while falling
- Damages C8 and T1 roots
101
presentation of brachial plexus syndrome
1. **Sharp, burning** shoulder pain with **radiculopathy** in the affected nerve root distribution
1. Weakness is common
1. Evaluate **sensation** to light touch, **motor function, & DTRs**
1. Any injuries to **C8-T1** may be associated with **_Horner’s syndrome_**
1. Assess lower extremities for spinal cord involvement
1. Look for **associated injuries**
102
diagnostics for brachial plexus syndrome
1. **X-Rays** - C-spine and shoulder to look for associated injuries
1. **CT C-spine** - r/o C-spine fx if x-ray abnml
1. **MRI** - Best for visualizing the spinal cord and nerve roots
- _Indicated if_: x-rays abnml or sx persists
1. **EMG/NCS** - May help differentiate specific location of nerve dysfunction
103
management for brachial plexus syndrome?
Pt ed for athletes?
1. **conservative**
- Strengthening and stretching exercises
- Splinting in neutral position of any joints affected by paralyzed muscles
- **Encourage PROM** to reduce joint stiffness or tendon constrictures
2. Athletes **must have complete resolution** of sx and normal PE before allowed to return to activity
104
5 Structures of the Thoracic Outlet
1. First rib
1. Subclavian artery and vein
1. Brachial plexus
1. Clavicle
1. Lung apex
105
* 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 y/o
Thoracic Outlet Syndrome
106
1. _Aching pain/paresthesia_
2. _Intermittent swelling & discoloration_
3. Fatigue, weakness, and aching pain of extremity
4. **exacerbated by lifting the arm above the head**
5. Palpate **supraclavicular fossa** to assess for a mass
6. Palpate for distal UE pulses
7. Check sensation & motor function cervical nerve roots
8. **(+) Elevated arm stress test**
dx?
Thoracic Outlet Syndrome
107
how to perform elevated arm stress test?
* Both shoulders abducted at least 90 degrees and supported posteriorly. The patient opens & closes fists at a moderate speed for 3 minutes.
* **POSITIVE** test if reproduced neuro &/or vascular s/s
108
diagnostics for thoracic outlet syndrome
1. **X-Ray**
- AP & lateral C-spine - r/o congenital anomalies
- PA/lateral CXR - r/o apical lung tumors
2. **MRI** - r/o cervical disc rupture or cervical spondylosis
109
management for thoracic outlet syndrome
1. MC tx **non-surgically**
- 3-6 m home exercise programs
- Emphasize **muscle strengthening & posture exercises**
2. Avoid strenuous activities, placing straps over shoulders, and any activity that exacerbates symptoms
3. NSAIDs, muscle relaxers, TENS unit
