Mss 05: Upper Extremity Injury

Front 1

What are the possible mechanisms of a fracture?

Back 1

- Acute - sudden impact of large force exceeding strength of bone
- Stress - from repetitive submaximal stresses
- Pathologic - from normal forces to diseased bone

Front 2

What would lead you to think a fracture is "open"? What happens then?

Back 2

- Bleeding +/- fragment
- Orthopedic emergency - needs to be surgically washed out immediately

Front 3

What signs would point towards a fracture during the physical exam?

Back 3

- Deformity
- Bony point tenderness (they can point to exactly where pain is located)
- Pain w/ loading bone (indirect loading especially useful)

Front 4

What are examples of indirect loading tests?

Back 4

- Axial loading - push proximally on finger / hand
- Bump test - bump heel - feel pain higher up in leg
- Fulcrum test - push down on ankle
- Hop test - detect stress fracture

Front 5

What are the imaging tools to detect a fracture?

Back 5

- Plain x-rays
- CT scan
- Bone scan (detect stress fracture)
- MRI

Front 6

What course of treatment should be used for a fracture?

Back 6

- Immobilization (in general)
- Avoidance of NSAIDs - may interfere with bony healing via prostaglandins

Front 7

What should you be worried about if someone falls onto out-stretched hand (FOOSH), has wrist pain, and snuffbox tenderness to palpation?

Back 7

Scaphoid Fracture - scaphoid can be felt through snuffbox

Front 8

What is your initial treatment for someone who falls onto out-stretched hand (FOOSH), has wrist pain, and snuffbox tenderness to palpation?

Back 8

Immobilization with splint (this is standard for any time you suspect a fracture) - even if you only suspect the fracture because you want to make sure it does not necrose

Front 9

Which bones in the body have "vulnerable" blood supply?

Back 9

- Watershed region: central navicular
- Retrograde (worry about necrosis): scaphoid, talus, femoral head (adults)

Front 10

What should you be concerned about during a potential scaphoid fracture?

Back 10

Potentially becoming necrotic - a few branches of radial artery are delivering nutrients to distal half, fracture could cause loss of blood supply to proximal half (leading to necrosis)

Front 11

What are the contents of the Snuffbox?

Back 11

- Radial nerve
- Radial artery
- Cephalic vein
* Scaphoid bone = floor

Front 12

What are the clinical findings of a Scaphoid fracture?

Back 12

- Pain
- Tenderness and swelling in anatomical snuffbox
- Commonly after fall on outstretched hand (FOOSH)
- Fracture often results in osteonecrosis of proximal/medial half (arteries only enter distal half)

Front 13

Where is the most common site of fracture to the Scaphoid?

Back 13

Middle third (waist)

Front 14

What are the four types of femoral head fractures?

Back 14

1. Impacted fracture
2. Non-displaced fracture
3. Partially displaced fracture
4. Displaced fracture

Front 15

What provides the blood supply to the femoral head? What is the significance of this in a femoral head fracture?

Back 15

- Chiefly from medial circumflex femoral artery
- Artery of ligament is usually insignificant
- In a femoral head fracture this may tear the medial circumflex femoral artery leading to osteonecrosis

Front 16

A patient has had recurrent episodes of shoulder dislocations and shoulder pain, significant crepitus, pain w/ active and passive motion, full ROM, normal strength, and a positive apprehension sign; what do you suspect?

Back 16

Arthritis (d/t recurrent dislocations damaging the joint / labrum)
- Left image = arthritis
- Right image = normal

Front 17

What are some common history and exam findings for Arthritis?

Back 17

- Stiffness, especially after rest
- Worse after prolonged use
- Joint line tenderness
- Mild swelling
- Deformity
- Damage to articular cartilage surface

L image = arthritis; R image = normal

Front 18

Patient has limited ROM, gradually tightening endpoint, and possibly pain; what do you suspect?

Back 18

Adhesive Capsulitis

Front 19

What happens in adhesive capsulitis? Cause? Risk factors?

Back 19

- Capsular thickening, inflammation, and scarring, which restrict joint movement
- Cause: idiopathic (not sure) or post-injury
- Risk factors: injury, diabetes, thyroid disease

- Edema shows up lighter in MRI

Front 20

What are the phases of Adhesive Capsulitis?

Back 20

Limited ROM:
1. Freeze phase = painful early w/ decreasing ROM
2. Frozen phase = non-painful w/ stable, decreased ROM
3. Thawing phase = non-painful w/ improving ROM

Front 21

How should you treat Adhesive Capsulitis?

Back 21

- Reassurance
- Educate and set expectations: good news is it will get better, unfortunately it could take up to 2 years
- Maintenance of ROM
- Pain control

Front 22

A patient comes in and says 2 weeks ago he felt a pop in his shoulder when pulling on a rusted, frozen bolt; he has full ROM and normal strength; what do you suspect?

Back 22

Long head biceps tendon rupture
- Bulk of muscle is distal (so either short or long head tendon ruptured)
- Cavity in shoulder indicates long head

Front 23

How should a long head biceps tendon rupture be treated?

Back 23

- Need to do surgery relatively soon (within month) to prevent scarring of ruptured tendon in wrong position
- Long head tendon brought through slit in short head tendon and sutured to margins and to coracoid process

Front 24

What does the term "Enthesopathy" mean?

Back 24

Disorder of muscular or tendinous bony attachment

Front 25

What does the term "Tendinitis" mean?

Back 25

Acute inflammation of tendon (e.g., after trauma from blow or pull)

Front 26

What does the term "Tendinosis" mean?

Back 26

Chronic degenerative condition of tendon (e.g., submaximal irritation)

Front 27

What is the difference between "tendonitis" and "tendinosis"?

Back 27

- Tendinitis - acute inflammation
- Tendinosis - chronic degenerative condition

Front 28

What happens in a "strain"?

Back 28

Muscle fiber damage from over-stretching / eccentric loading (muscle lengthening during firing)

Front 29

What happens in a "sprain"? General symptoms?

Back 29

- Ligamentous damage from overloading
- Causes instability or laxity and swelling

Front 30

What are the symptoms of a strain (muscle fiber over-stretching)?

Back 30

- Stiffness
- Bruising
- Swelling
- Soreness

Front 31

In which case is the risk vs. benefit ratio of NSAIDs most favorable?
A. Acute patellar tendinitis
B. Immediate post-op pain
C. Chronic lateral epicondylitis
D. Chronic shoulder instability
E. Stress fracture of the femur

Back 31

A - Acute patellar tendinitis

Front 32

A patient presents after landing on shoulder after a failed BMX jump landing, he complains of pain and limited ROM; what happened?

Back 32

Grade II Acromioclavicular sprain:
- AC ligament tear and Coracoclavicular ligament stretch
- Clavicles are even (therefore not grade 3)

Front 33

What is the most common cause of an Acromioclavicular (AC) sprain? Presentation? Exam?

Back 33

* Cause: Fall directly onto shoulder
* Pain w/ overhead motions
* Deformity of superior shoulder
- Painful arc of abduction over 150 degrees (loading AC joint)
- Pain and deformity at AC joint
- Pain w/ cross-body adduction of arm (positive cross-chest test)

Front 34

What does pain w/ cross-body adduction of arm indicate (positive cross-chest test)?

Back 34

Acromioclavicular Sprain (AC)

Front 35

What are the four grades of Acromioclavicular Sprains?

Back 35

- I = AC ligament stretch
- II = AC ligament tear and Coranoid-Clavicular (CC) ligament stretch
- III = complete tears of both AC and CC ligaments
- IV+ = complete tears + clavicular displacement

Front 36

What grade would you consider this injury (normal on left, injured on right)?

Back 36

Grade II - the clavicle is not highly raised up, therefore Coracoclavicular ligament is not torn completely, but there is a separation of acromion and clavicle indicating AC joint tear

Front 37

How should you treat Acromioclavicular Injuries?

Back 37

- Non-operative: grades I and II
- Either: grade III
- Operative: grade IV+

Front 38

What are the three grades to a sprain?

Back 38

- I = microscopic damage w/ no increased laxity, but pain w/ stress
- II = partial tear w/ increased laxity and pain
- III = complete tear w/ significant laxity and less pain

Front 39

A football player comes in after attempting an arm tackle in which he felt a pop with immediate onset of shoulder pain and inability to move the shoulder; he has normal neck and elbow strength/ROM (neurovasculary intact), but the shoulder he refuses to move; what do you suspect?

Back 39

Anterior glenohumeral dislocation

Front 40

What are the types of glenohumeral dislocation?

Back 40

- Subcoracoid dislocation
- Subglenoid dislocation
- Subclavicular dislocation
(all anterior, the case 90% of the time)

Front 41

What is the point that sticks out of the shoulder when the shoulder is dislocated?

Back 41

Acromion Process

Front 42

What are the variations of joint stability?

Back 42

- Dislocation - complete displacement
- Subluxation - transient, partial displacement (pops back in)
- Laxity - normal variant in joint looseness

Front 43

What is it called when a joint transiently is partially displaced?

Back 43

Subluxation

Front 44

What is the most effective passive stabilizer of the glenohumeral joint?

Back 44

Vacuum phenomena

Front 45

What can cause a glenohumeral dislocation?

Back 45

- Forced extension, abduction, and external rotation of arm (e.g., open arm tackle or fall onto abducted arm)
- Direct blow to posterior shoulder

Front 46

During an examination, how will someone with a dislocated shoulder present?

Back 46

- Arm held by opposite hand in slight abduction and external rotation
- Alteration of shoulder contour including a prominent acromion, humeral head anterior to acromion and adjacent to coracoid
- Positive apprehension test - feeling of instability w/ stress

Front 47

What nerves should be tested in someone with a dislocated shoulder?

Back 47

Sensation of axillary (deltoid area) and musculocutaneous (lateral forearm) nerves

Front 48

What symptoms can be seen in carpal tunnel syndrome? Cause?

Back 48

- Thenar wasting (takes >1 month to appear)
- Parasthesias (tingling, pain, or both in sensory distribution of median nerve)
- Cause: compression of median nerve

Front 49

What do you suspect in this patient?

Back 49

Carpal Tunnel Syndrome d/t thenar wasting

Front 50

What is the sensory distribution of median nerve?

Back 50

Palmer side: 1st-3rd fingers + 1/2 of 4th finger + palm
Dorsal side: distal portion of 1st-3rd fingers + distal portion of 1/2 of 4th finger

Front 51

What muscles are innervated by median nerve?

Back 51

* Remember MED-LOAF *
- L = Lumbricals 1 and 2
- O = Opponens Pollicis
- A = Abductor Pollicis Brevis
- F = Flexor Pollicis Brevis

Front 52

Patient presents with L shoulder pain x 1 week, felt pop in shoulder while lifting heavy box, company MD ordered shoulder X-ray and said it was negative
- L shoulder ROM abduction 90deg. and flexion to 60deg.
- Diffuse swelling over L clavicle and anterior chest wall
- Crossover test is painful
- Diffuse tenderness over L clavicle
- Strength 5/5 deltoid, IR, supraspinatus, ER, and liftoff
- Impingement tests painful in L anterior chest
- Symmetric laxity w/ negative apprehension test

What do you do next?

Back 52

Order clavicle X-ray = fractured

Front 53

If you have a patient that fractures a bone and has a history of cancer / chemotherapy, what should you do?

Back 53

Bone scan (to check for metastases)

Front 54

Patient presents w/ shoulder pain w/ overhead motions, exam shows full ROM, pain over 80deg. of abduction, weak to external rotation; what do you suspect?

Back 54

Rotator cuff injury (pain w/ abduction between 80-150 degrees)

Front 55

If a patient has an acute complete rotator cuff tear, when should surgery be done?

Back 55

- Large tear or in a younger athletic patient
- Sooner rather than later because if you wait too long it will be impossible to repair completely (d/t scarring, etc)

- Non-operative for small tears and tendonopathies

Front 56

What are the symptoms of a rotator cuff injury?

Back 56

- Pain w/ overhead motions

Impingement signs: positive
- Neer's test - pain when arm elevated through forward flexion
- Empty can test (Jobes) - pain when arms pushed downward
- Hawkins test - pain w/ resisted external rotation w/ elbow flexed and across body

- Profound weakness to abduction (drop arm test) if complete tear
- Painful arc of abduction (80-120 deg)
- Tender at insertion of supraspinatus tendon on greater tuberosity of humerus

Front 57

If a joint is hot, swollen, red, and extremely painful (especially with passive motion), what diagnosis do you need to rule out?

Back 57

Septic joint

Front 58

If a patient has night pain (especially with constitutional signs, e.g., weight loss), what diagnosis do you need to rule out?

Back 58

Tumor

Front 59

If a patient has a deformity and loss of motion, what diagnosis do you need to rule out?

Back 59

Dislocation and/or fracture

Front 60

If a patient has rapidly progressing neurologic changes, and the following in forearm or leg: pallor, weak/absent pulse, pain w/ passive motions, what diagnosis do you need to rule out?

Back 60

Compartment syndrome
(not a sufficient amount of blood to supply the muscles and nerves with oxygen and nutrients because of the raised pressure within the compartment)

Front 61

If a patient has significant, sudden onset of limb swelling, pain, and bluish skin changes, what diagnosis do you need to rule out?

Back 61

DVT

Front 62

If a patient has point bony pain and bleeding, what diagnosis do you need to rule out?

Back 62

Open fracture

Front 63

What does "morning stiffness" that is better with rest (worse after prolonged use) suspicious for?

Back 63

Arthritis

Front 64

What does pain with only active motion / resistance, suspicious for?

Back 64

Muscle or tendon injury

Front 65

What is pain with both active and passive motion suspicious for?

Back 65

Articular injury / damage

Front 66

What is musculoskeletal weakness suspicious for?

Back 66

Muscle or tendon injury

Front 67

What is instability suspicious for?

Back 67

Ligament injury

Front 68

What is locking suspicious for?

Back 68

Loose body or cartilage injury

Front 69

What is the basic strength grading scale?

Back 69

- 5/5 = normal
- 4/5 = weak
- 3/5 = can only move against gravity
- 2/5 = can move, but not against gravity
- 1/5 = muscle contractions, but no motion
- 0/5 = no contraction

Front 70

What is the basic reflex grading scale?

Back 70

- 4+ = Clonus
- 3+ = hyperactive, but no clonus 
- 2+ = “normal”
- 1+ = hypoactive 
- 0 = absent

Front 71

What is the normal capillary refill?

Back 71

< 2 seconds

Front 72

What is the pulse intensity grading scale?

Back 72

- 0 = absent
- 1+ = faint, but detectable
- 2+ = diminished
- 3+ = “normal”
- 4+ = bounding

Front 73

If there is a painful shoulder arc of abduction from 80-150deg, what does this suggest? >150deg.?

Back 73

- 80-150 deg. consistent w/ rotator cuff problem
- >150 deg. consistent w/ AC pathology

Front 74

What are the muscles in the Rotator Cuff?

Back 74

- Supraspinatus
- Infraspinatus
- Teres minor
- Subscapularis

Front 75

How do you test the Supraspinatus?

Back 75

Full can test: patient holds arms at 90 deg of abduction and 30 deg. anterior to coronal plane w/ elbows extended and thumbs pointing up
- Resist examiner pushing down

Front 76

What muscle is being tested here (full can test)?

Back 76

Supraspinatus

Front 77

How do you test the Infraspinatus and Teres Minor?

Back 77

External rotation

Front 78

How do you test the Subscapularis?

Back 78

Liftoff test: patient places hand behind back and lifts hand off back w/ examiner resisting

Front 79

What muscle is being tested here (lift off test)?

Back 79

Subscapularis

Front 80

How do you assess for joint stability?

Back 80

Apprehension test: patient expresses apprehension to loading of joint in manner that simulates dislocation forces

Front 81

How do you assess for carpal tunnel syndrome (integrity of median nerve)?

Back 81

- Tinel's sign - tap over median nerve
- Phalen's sign (picture)
- "Positive" causes burning, tingling or numb sensation over the thumb, index, middle and ring fingers

Front 82

What is being tested here (Tinel's sign)?

Back 82

- Tapping over median nerve in carpal tunnel
- "Positive" causes tingling in the thumb, index, middle finger and the radial half of the fourth digit

Front 83

What is being tested here (Phalen's sign)?

Back 83

- Moderately increases the pressure in the carpal tunnel via this mass effect, pinching the median nerve
- "Positive" causes burning, tingling or numb sensation over the thumb, index, middle and ring fingers

Front 84

What are the stages of healing after musculotendinous injury?

Back 84

1. Degeneration or disruption
2. Inflammation
3. Regeneration
4. Remodeling

Front 85

What happens in the first step of repair after musculotendinous injury?

Back 85

Degeneration or disruption:
- Proteases released by myofiber degeneration (auto-digestion of damaged tissued and chemotaxis of neutrophils/macrophages to area)
- Vessel injury exposes clotting factors and platelets to collagen, which causes activation of complement and kinin systems, generates plasmin, and stimulates platelet degranulation
- Clot of fibrin, platelets, red cells, and debris serves as scaffolding for fibroblast repair

Front 86

What happens in the second step of musculotendinous injury healing after degeneration or disruption?

Back 86

Inflammation:
- Immediately following degeneration, attraction of neutrophils, lymphocytes, and macrophages
- Macrophages induce local inflammatory response (release cytokines and chemotactic factors by T cells
- Recruit progenitor and satellite cells

Front 87

What happens in the third step of musculotendinous injury healing after inflammation?

Back 87

Regeneration:
- As early as 24 hrs
- Mostly proliferation of surrounding fibroblasts and migration into wound
- Phagocytes release enzymes to digest exudate, fibrin clot, and debris
- Vascular budding and recanalization restores vascular connections in 3-4 days
- Granulation tissue bridges small gaps by 7-10 days
Spread of area of inflammation and edema into surrounding normal tissue by 21 days
- 6 weeks surrounding tissue return to normal

Front 88

What happens in the fourth step of musculotendinous injury healing after regeneration?

Back 88

Remodeling:
- 6 months - fibrils more oriented to lines of stress
- 1-2 years final remodeling

Front 89

What are the stages of healing after bony injury?

Back 89

1. Inflammation
2. Callus formation
3. Consolidation
4. Remodeling

Front 90

What happens in the first step of repair after bony injury?

Back 90

Inflammation:
- Within 8 hrs
- Proliferation of cells under periosteum and in breached medullary canal
- Ends surrounded by cellular tissue that bridges gap
- Clot reabsorbed as capillaries regrow

Front 91

What happens in the second step of bony injury healing after inflammation?

Back 91

Callus formation:
- Soft callus (2-3 weeks)
- Hard callus (union 4-6 weeks upper extremity; 8-12 weeks lower extremity)

Front 92

What happens in the third step of bony injury healing after callus formation?

Back 92

Consolidation:
- Woven bone converted to laminar bone
- Osteoclasts burrow through debris at fracture line
- Osteoblasts fill remaining spaces
- Strong enough for normal loads
- 6-8 weeks for upper extremity; 12-16 weeks for lower extremity

Front 93

What happens in the fourth step of bony injury healing after consolidation?

Back 93

Remodeling:
- Thicker lamellae in response to stress
- Reabsorption of underloaded areas
- Medullary reformation

Front 94

What are some variables that affect bony healing?

Back 94

- Bone type (cancellous faster than cortical)
- Fracture type (spiral faster than transverse)
- Blood supply (good faster than poor)
- Age (kids faster than adults)
- General health

Front 95

When do you do an apprehension test? What makes it positive?

Back 95

- Test when patient is currently in normal anatomical alignment (reduced), not when dislocated
- Feeling of pain = negative; feeling of apprehension / instability = positive

Front 96

When is surgery indicated for a shoulder dislocation?

Back 96

Adolescent athlete and high level athletes

Front 97

What is the cause of medial epicondylitis / golfer's elbow?

Back 97

Overuse of wrist flexors (especially pronator teres and flexor carpi radialis)

Front 98

What are the symptoms of medial epicondylitis / golfer's elbow?

Back 98

- Painful medial elbow w/ secondary weakness
- Tenderness on medial epicondyle and pain w/ resisted wrist flexion and forearm pronation

Front 99

What is the cause of lateral epicondylitis / tennis elbow?

Back 99

- Overuse from repetitive extension (especially extensor carpi radialis brevis)
- Incorrect technique and poorly fitted equipment are contributory

Front 100

What are the symptoms of lateral epicondylitis / tennis elbow?

Back 100

- Pain over lateral elbow radiating into forearms; late - weakness
- Tenderness over lateral epicondyle
- Pain w/ resisted wrist dorsiflexion and middle finger extension

Front 101

What is the cause of a ganglion?

Back 101

Overproduction of fluid by a joint of tendon sheath - filled with thick gelatinous material

Front 102

What are the symptoms of a ganglion?

Back 102

- Lump usually firm and mobile (most common in wrist, hand, foot, and ankle)
- Pain - if any - usually caused by compression of nearby nerve or pinching of ganglion w/ motion

Front 103

How do you treat a ganglion?

Back 103

- Clinical observation
- Aspiration - if painful, but often recurs
- Surgery - for definitive treatment, but may still recur