PANCE Blueprint Musculoskeletal (8%)

Upper extremity disorders (PEARLS)

Disorders of the shoulder

Shoulder Fractures/dislocations

Shoulder Fractures

Patient will present as → a 30-year-old male arrives at the emergency room after a motor vehicle accident. Upon arrival, he has difficulty breathing and reports shoulder pain. On physical exam, he has decreased breath sounds on the right side and significant tenderness of his right shoulder. There is overlying ecchymosis, swelling, and erythema over his right scapula and limited range of motion.  
  • Common in elderly patients
  • A complication is adhesive capsulitis or rotator cuff tear: Immobilize for 2-3 weeks then begin with gentle passive ROM and modalities. Progress to light strengthening after 6 weeks.
  • Get an MRI to rule out rotator cuff tear
  • Scapular fractures are often missed after MVA

Shoulder Dislocation

Patient will present as →  an 80-year-old woman arrives at the emergency room with severe right shoulder pain and immobility. She fell down the steps outside her house and landed on her right side two hours prior to presentation. On exam, her right arm is abducted and externally rotated. She has decreased sensation to touch over the lateral aspect of her right shoulder. Radiographs demonstrate an anterior shoulder dislocation.

Mode of injury: fall on an outstretched arm (full abduction and extension)

  • Contact sports in younger patients
  • Falls in older patients

Anterior dislocation is the most common - 95% (Remember ARM = ANTERIOR)

  • 2-4% of shoulder dislocations are posterior (common with a seizure)
  • < 1% of shoulder dislocations are inferior

Presentation: In anterior dislocation, the arm is abducted and externally rotated 

  • Different from posterior dislocation in which the arm is held adducted and internally rotated
  • "Squaring" of the shoulder: loss of rounded appearance (humeral head) and sharp prominence of the acromion ("squaring")

Radiographs: are indicated in any patient in whom a shoulder dislocation is suspectedshoulder dislocation

  • Anteroposterior (AP) and axillary lateral or scapular Y-views must be taken

Associated conditions

  • Bankart lesionfracture of the anterior inferior glenoid following impaction of the humeral head against the glenoid.
  • Hill-Sachs lesion (dent in the humeral head): compression chondral injury of the posterior superior humeral head following impaction against the glenoid
  • Axillary nerve injury
    • Transient neurapraxia present in 5% of shoulder dislocations
    • May present with numbness or tingling over the lateral shoulder
  • Rotator cuff tear: more likely in older patients
  • labral tear = labrum is the cartilage that surrounds the glenoid.

  • Axillary nerve: C5-C6 fibers. Motor: deltoid, teres minor, triceps. Sensation: shoulder joint, inferior deltoid
  • Musculocutaneous nerve: C5-C7 fibers. Motor: coracobrachialis, biceps, brachialis. Sensory: radial side forearm. Decreased biceps reflex


  • Reduce, postreduction films, sling, and swath, physical therapy

Clavicle Fractures

Patient will present as → a 23-year-old woman arrives at the emergency room after a biking accident. She reports acute pain after falling on her shoulder. On physical exam, there is swelling, erythema, and tenderness on the anterior aspect of her right shoulder. No tenting of the skin is noted. Distal pulses are intact, and there is no motor or sensory deficits. She is sent for further imaging.

Method of injury: most commonly from direct fall on the shoulder (adults and children)

  • A direct blow to the lateral aspect of the shoulder
  • birth trauma (newborns)

Classified based on location (medial third, middle third, and lateral third)Clavicular Fracture Child

Physical exam:

  • Swelling, erythema, and deformity of the clavicle. Tenderness to palpation - worse with passive and active movement.
  • Tenting of skin overlying fracture

Radiographs: anteroposterior and clavicle view


  • Simple arm sling or figure-of-eight sling: 4-6 weeks in adults, ortho consult if proximal 1/3
  • Begin PT after 4 weeks with light strengthening after 6 weeks
Soft tissue injuries of the shoulder

AC Joint Separation

Patient will present as → a 37-year-old right-hand dominant male fell off his bicycle four days ago and injured his left non-dominant shoulder. There is an abnormal contour of the left shoulder with an elevation of the clavicle, AC joint tenderness, and pain with cross-chest testing. A radiograph is shown here. The axillary radiograph shows no anteroposterior translation.

Patient will present after → fall directly to the shoulder or outstretched hand

  • Deformity: elevation of clavicle and point tenderness and pain with cross-chest testing
  • DX: to appropriately grade acromioclavicular separations, an x-ray is taken with the patient holding a weight to assess the level of injury to the joint.

Biceps Tendonitis

Patient will present as → a 33-year-old man who complains of left anterior shoulder pain for 4 weeks. The pain is made worse with overhead activities. On examination, you note maximal pain in the shoulder with palpation between the greater and lesser tubercle. Pain in the shoulder is exacerbated when the arm is held at the side, elbow flexed to 90 degrees, and the patient is asked to supinate and flex the forearm against your resistance.

Patient will present with → pain at the biceps groove

  • Pain with resisted supination of elbow
  • X-Ray to r/o fracture and MRI to r/o rotator cuff tear

Yergason’s test:

Rotator cuff tendinopathy/tear

Patient will present as → a 69-year-old male with right shoulder pain for the past several months. He reports that he cannot reach above his head without severe pain. As a retired carpenter, he reports that this has significantly impacted his quality of life. Additionally, he is unable to lie on his left side at night due to shoulder pain. On physical exam, there is focal tenderness over the left anterolateral shoulder. Radiography reveals reduced space between the acromion and humeral head.


  • Shoulder pain with overhead activity or at night when lying on arm
  • Weakness and immobility after acute injury
  • DX with MRI

Four Muscles of the rotator cuff:

  1. Supraspinatus
  2. Subscapularis
  3. Infraspinatus
  4. Teres minor

Rotator cuff inflammation/impingement:

  • Neer’s test: Forward arm flexion, press greater tuberosity, and supraspinatus muscle.
  • Hawkins test: Abduct shoulder 90 degree, flex elbow 90, rotate arm to limit.

Supraspinatus tear or inflammation:

  • Empty can test: 90 degree abduct, 30 degree flex, rotate internal. Apply downward pressure.
  • Full can test: 90 degree abduct, 30 degree flex, rotate external. Apply downward pressure.
  • Arm drop: Arm passively abducted and actively adducted slowly

Subscapularis tear or inflammation:

  • Lift off test: Elbow 90 degree, rotate medially against resistance.

Teres minor/infraspinatus tear or inflammation:

Adhesive Capsulitis - AKA frozen shoulder

Patient will present as → a 50-year-old female with a past medical history of diabetes mellitus complaining of prolonged shoulder pain and stiffness for 6 months. For the past few months, she reports persistent left shoulder pain that also occurs at night. She denies history of traumatic injury. On physical exam, she has decreased active and passive range of motion. She is also unable to reach 90° with passive abduction. Resisted shoulder range of motion testing is pain-free and demonstrates no strength loss. She is sent home with range of motion exercises and counseled that this will likely resolve with time.
  • Often post fracture, looks like rotator cuff injury
  • decreased active and passive range of motion
  • Apley scratch test the patient tries to bring hands together on the back while one hand comes from above and the other from below
  • Rehab ROM therapy are the mainstay of treatment.  Anti-inflammatories, intra articular steroid injections and heat


Patient will present as → a 70-year-old male with an insidious onset of left shoulder pain that is exacerbated by overhead activities and while lifting objects away from his body. He is a retired mechanic of 35 years. The patient reports that over the last several months he has been having difficulty sleeping because of the pain. On physical examination, there is notable tenderness over the left anterolateral shoulder and passive forward flexion >90° causes severe pain. An x-ray reveals proximal migration of the humeral head and calcification of the coracoacromial ligament.
  • Pain with reaching or lifting
  • pain with overhead motions
  • Will have positive impingement tests: check the subscapular nerve and the supraspinatus
    • (+) Neer test: arm fully pronated (thumb's down) with pain during forward flexions while the shoulder is held down to prevent shrugging
    • (+) Hawkins: Elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation
    • (+) Drop arm test: pain with inability to lift the arm above shoulder level or hold it or severe pain slowly lowering arm after shoulder abducted to 90 degrees
  • Crepitus with ROM
  • X-ray may show a subacromial spur

Shoulder Bursitis

Patient will present as → a 42-year-old man with complaints of right shoulder pain. He does not remember any specific injury but has been playing a lot of tennis during the past 4 months. He tells you that “opposing players no longer fear my serve.” It has become difficult and painful for him to reach overhead and behind him. Even rolling onto his shoulder in bed is painful. On examination of the right shoulder, there is full range of motion in all planes with obvious discomfort at end ranges of flexion, abduction, and internal rotation. There is significant pain when you place the shoulder in a position of 90 degrees flexion and then internally rotate. There is also moderate weakness with abduction and external rotation of the shoulder. The rest of the musculoskeletal examination is normal.
  • Pain often not associated with trauma
  • Pain on motion and at rest, can cause fluid to accumulate
  • Aspirate if fever, diabetic or immunocompromised

Glenohumeral joint Osteoarthritis

Patient will present as → a 66-year-old male with chronic right shoulder pain and crepitus. On physical exam, his rotator cuff strength is 5/5. He has pain with both passive and active range of motion. Radiographs are shown here and here. An MRI is performed and shows no evidence of a rotator cuff tear.
  • The more the patient does the more pain he/she will have
  • Treat with joint injections

Disorders of the Forearm, Wrist and Hand

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Fractures and dislocations of the forearm, wrist and hand
Greenstick Fractures

  • Incomplete fracture with cortical disruption and periosteal tearing on the convex side of the fracture (intact periosteum on the concave side) "bowing"

Torus (Buckle) Fractures

  • Incomplete fracture with wrinkling or bump on the metaphyseal-diaphyseal junction (where the dense bone meets the more porous bone) due to axial loading.
Greenstick and Torus Fractures

Upper Arm

Humerus Fractures

Patient presents as → a 73-year-old female who arrives at the emergency room with left arm pain after tripping and falling on the sidewalk. She developed immediate pain throughout her arm. The patient has a history of osteoporosis for which and has been on bisphosphonate therapy for 12 months. Radiographs of her left arm demonstrate a spiral midshaft humeral fracture. She is given appropriate analgesia and placed in a coaptation splint.
  • Proximal in the elderly (think osteoporosis)
  • Shaft commonly a pathological fx from tumors
  • Humerus fractures are the most common site of radial nerve injury (common exam question)
  • Distal (less common): anterior fat pad or "sail" sign
  • Supracondylar in children (above the growth plate) – worry about compartment syndrome and the brachial artery
  • Treat with sugar tong splint with ortho follow up in 24-48 hours

Humerus Fracture

Humerus Fracture


Supracondylar fracture

Patient presents as → a 7-year-old girl who fell from a jungle gym and lands on her outstretched left hand. She develops immediate-onset left elbow pain and swelling. On exam, her arm is held in 30 degrees of extension and she is unable to move her elbow due to pain. A radiograph is shown here and demonstrates a dorsally displaced supracondylar humerus fracture.
  • Usually, occurs from fall to an outstretched hand
  • X-ray: ANTERIOR fat pad sign = dark area on either side of the bone
  • Make sure to check for neurologic or vascular involvement - may cause median nerve and brachial artery injury, as well as radial nerve injury
  • Treat: non-displaced - splint displaced - open reduction with internal fixation all displaced

Supracondylar fracture

Radial Head Fracture

Patient presents as → a 35-year-old concert cellist presents after falling onto a pronated, outstretched hand this morning. She complains of lateral elbow pain. Examination reveals lateral elbow tenderness, and an 80-degree arc of flexion-extension, and a 60-degree arc of prono-supination, with extremes of motion limited by pain. There is no bony block to motion. Radiographs of her injury are performed and reveal a Mason Type I radial head fracture.
  • Usually from fall to an outstretched hand
  • Treat with sling, long arm splint at 90 degrees, open reduction, and internal fixation

Radial Head Fracture

Radial Head Fracture

Nursemaid's elbow

Patient will present as → a 3-year-old boy is brought to the clinic because of left elbow pain. The father of the patient says that after picking up the boy from daycare, he noticed his son was not moving his elbow and complained of pain. Patient is holding his left elbow flexed and pronated. Physical examination shows tenderness over the lateral aspect of the left elbow joint on palpation.

Nursemaid's elbow is a dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm, such as by an adult tugging on an uncooperative child or by swinging the child by the arms during play. The technical term for the injury is radial head subluxation.

  • Common pediatric presentation, generally occurring between the ages of 1 and 3 years old
  • Generally, occurs with a pulling upward type of motion while the child has an outstretched arm
  • The child refuses to move the arm on presentation which is held in flexion and pronated, there is minimal swelling
    • Characterized by significant pain, partial limitation of flexion/extension of the elbow, or total loss of pronation/supination in the affected arm

DX: The diagnosis is made clinically and radiography is unnecessary unless is needed to exclude fractures or other dislocation.

TX: The supination-flexion technique is the classic method of reducing a subluxed radial head. It has a success rate of 80-92%

  • Always ensure the child spontaneously uses the arm after reduction before discharging to confirm success

Forearm fractures


13-year old with severe pain in left mid-forearm after falling awkwardly on an outstretched left arm, unable to move the left arm without significant pain (watch video)

Ulnar forearm fractures

Nightstick fracture

Patient presents as → an otherwise healthy 30-year-old male who sustained a left forearm injury as a result of a fall from a 15-foot ladder. Initial examination in the emergency room reveals a clean 2-centimeter laceration over the volar forearm, pain and swelling of the affected arm along with decreased active and passive range of motion. Radial and ulnar pulses are intact. Radiographs are performed and are shown here.
  • Isolated fractures of the ulna, typically transverse and located in the mid-diaphysis and usually resulting from a direct blow.
  • Treat with a functional brace with good interosseous mold for isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx)
    • ORIF if displaced

Nightstick Fracture

Monteggia fracture

Patient presents as → a 10-year-old man who arrives at your ED complaining of severe right elbow and forearm pain after sustaining a blunt injury to his right arm. On examination, the affected arm is swollen and tender around his elbow. Radiographs demonstrate a displaced fracture of the proximal ulnar diaphysis and radial head dislocation.
  • Traumatic injury to the elbow and forearm characterized by the presence of two bony injuries:
    • Proximal ulnar shaft fracture with radial head dislocation
  • Traumatic injury - Fall On an OutStretched Hand (FOOSH) or a direct blow to the ulna
  • Radial nerve injury with wrist drop in 17% of patients
  • Treat with open reduction and internal fixation

Monteggia fracture

Monteggia fracture

Radial forearm fractures

Galeazzi fracture -  Distal radial shaft fracture with dislocation of the ulnar-radial joint

  • mid distal radial shaft fracture with dislocation of radioulnar joint
  • Unstable fracture needs ORIF, long arm splint

Galeazzi Fracture

Galeazzi Fracture

Wrist Fractures

Colles fracture - distal radial fracture 


15-year old with "fall to an outstretched hand" now with acute onset, wrist swelling (view case)

  • Fall on outstretched hand causes distal radial fracture with distal segment protruding upward (dorsal (posterior) angulation) causing "dinner fork" deformity (mom “Colles” you for dinner)
  • Need lateral X-Ray to make the correct diagnosis, may cause extensor pollicis longus tendon rupture
  • Treat: Sugar tong splint/cast

Smith fracture - distal radial fracture

  • Fall with palm closed or blow to back of wrist causes distal radial fracture "reverse Colles" fracture with ventral (anterior) angulation and garden spade deformity
  • 3D's (dorsal displacement of the distal fragment) = your hand side is poking up!
  • median nerve injury is common (over time can develop carpal tunnel)
  • Treat: ortho for reduction/surgery or casting, PT for ROM and strengthening

Scaphoid Fracture: fall on outstretched hand (SNUFFBOX tenderness) = treat as a fracture

  • Pain along radial surface of wrist at anatomical snuffbox
  • Fracture may not be evident for up to 2 weeks
  • Complication is avascular necrosis
  • Treat: 10-12 weeks of casting with a thumb spica splint

Hand Fractures

Boxer's Fracture - Fracture at neck of 5th ± 4th metacarpal

Boxer's Fracture

13-year old with pain and edema over the 5th metacarpal (View Case)

  • Usually caused by punch with a clenched fist ReelDX
  • Look for associated carpal fractures
  • Treat: ulnar gutter splint with 60 degrees of flexion
Treat boxer's fractures with an ulnar gutter splint with joints at least 60 degrees flexion

Treat boxer's fractures with an ulnar gutter splint with joints at least 60 degrees flexion

Bennett's Fracture

  • Bennett fracture is an intraarticular fracture through the base of the 1st metacarpal (thumb) with large distal fragment dislocated radially and dorsally by abductor pollicis longus muscle
  • Treat: Unstable requires open reduction and internal fixation

Rolando's Fracture

  • comminuted Bennett's fracture
  • Treat: Unstable requires open reduction and internal fixation


Medial Epicondylitis - GOLFER'S/PITCHER'S ELBOW

  • Pain with resisted wrist flexion and pronation
  • Pain at the medial elbow epicondyle that may radiate to the wrist
  • Treat: rest, ice, NSAIDs, injection

Lateral Epicondylitis - TENNIS ELBOW

  • Pain with resisted finger or wrist extension
  • Treat: rest, ice, NSAIDs, injection

Olecranon Bursitis - SCHOLAR'S ELBOW

  • Abrupt GOOSE EGG swelling
  • r/o septic or gout may need to aspirate WBC > 5,000
  • NSAIDs, steroids, padding

Cubital Tunnel Syndrome - Ulnar Nerve Entrapment at the Elbow 

  • Over medial aspect of the elbow
  • Numbness and tingling in the 4'th and 5'th digits
  • Treat: NSAIDs, Bracing, surgery if refractory

Carpal Tunnel Syndrome

Caused by a compression of the median nerve in the carpal tunnel

  • Pain with numbness and tingling into the hand, sometimes worse at night
  • + Phalen (pushing backs of hands together) and + Tinel test (tapping over nerve) 
  • EMG studies and nerve conduction studies
  • Treat with a volar splint, NSAIDs, corticosteroid injections, and carpal tunnel surgery in refractory cases

De Quervain's Tenosynovitis

  • Pain and swelling at the base of the thumb often radiates into the radial aspect of the forearm
  • + Finkelstein (make a fist with the thumb inside, then ulnar deviate)
  • Treat: thumb spica splint x 3 weeks, NSAIDs x 10-14 days, steroid injections and PT

Gamekeeper's Thumb - SKIER'S THUMB (ACUTE)

Gamekeeper's Thumb

23-year old with acute onset, right thumb pain ReelDX (View Case)

  • Fall on an abducted thumb (hitchhiker)
  • laxity and pain with valgus stress.
  • Treat: referral to hand surgeon, may need surgical repair

Can involve a partial or complete tear of the ulnar collateral ligament

Dupuytren's Contracture – most often 4'th and 5'h digits

  • Is a flexion contracture of the hand due to a palmar fibromatosis, in which the fingers bend towards the palm and cannot be fully extended (straightened). It is an inherited proliferative connective tissue disorder that involves the hand's palmar fascia.
  • Patient will not be able to lay their hand flat on the table

an inherited proliferative connective tissue disorder that involves the hand's palmar fascia.


  • Avulsion of extensor tendon - with sudden blow to tip of extended finger with forced flexion
  • Patient is unable to straighten distal finger (flexed at DIP joint) commonly associated with an avulsion fracture of the distal phalanx
  • Treat: splint DIP uninterrupted extension x 6 weeks or surgical pinning

Commonly associated with an avulsion fracture of the distal phalanx

Boutonniere Deformity - TEAR AT PIP JOINT

  • Sharp force against tip of partially extended digit - hyperflexion of middle joint (flexion at PIP and extended at DIP) causing disruption of extensor tendon at base of middle phalanx
  • Treat: splint PIP in extension x 4-6 weeks with hand surgeon eval

Tears at PIP joint causes inability to extend the finger resulting in hyperflexion at PIP

Infections of the hand

  • Cellulitis: usually strep or staph
  • Paronychia: infection next to fingernail anywhere around the eponychium
    • Acute = bacterial
    • Chronic = fungal
  • Felon: Abscess in tip of finger
  • Herpetic whitlow: Herpes virus infection around the fingernail (thumb sucking)

Ganglion cyst

  • Small firm nodule (often on the back of the wrist)
  • Treatment is generally reassurance and observation
IM_MED_HandCarpalBones_v1.3_ There are 8 carpal bones, which can easily be remembered with the mnemonic, "Some Lovers Try Positions That They Can't Handle," representing the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate bones.

Hand Bones Picmonic

upper-limb-bones-humerus_5855_1483042056 The humerus is the largest bone in the upper extremity and has many important landmarks that serve as sites of muscle attachment and action. The greater and lesser tubercles serve as the insertion sites for the muscles of the rotator cuff, while the deltoid inserts on the deltoid tuberosity. Distally, the medial and lateral epicondyles are attachment points for muscles that act on the wrist. Several structures on the humerus also act to stabilize both the shoulder and elbow joint. The olecranon fossa, coronoid fossa, capitulum, and trochlea are all bony structures that contribute to the stability of the elbow joint.

Upper Limb Bones - Humerus Picmonic

upper-limb-bones-ulna-and-radius_5856_1483041814 The ulna and radius are the two distal bones of the arm. While the ulna sits medially, the radius is named for its lateral positioning when the body is prone. Important landmarks of the ulna include the olecranon process, coronoid process, trochlear notch, radial notch, styloid process and ulnar head. Meanwhile, important radius landmarks include the radial head and neck, the radial tuberosity, the styloid process, the ulnar notch, and Lister's tubercle.

Upper Limb Bones - Ulna and Radius Picmonic

IM_MED_HandMuscles_v1.4 The hand muscles can be divided into the thenar, hypothenar and intrinsic muscles. The thenar muscles include the opponens pollicis, abductor pollicis brevis, flexor pollicis brevis and adductor pollicis. The hypothenar muscles include the flexor digiti minimi brevis, abductor digiti minimi, opponens digiti minimi and the palmaris brevis. The intrinsic muscles include the interossei and lumbrical muscles.

Hand Muscles Picmonic

Lower back pain (ReelDx) (Prev Lesson)
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