Upper extremity disorders
| Shoulder Fractures/dislocations |
Shoulder FracturesPatient 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.
Shoulder DislocationPatient 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)
Anterior dislocation is the most common - 95% (Remember ARM = ANTERIOR)
Presentation: In anterior dislocation, the arm is abducted and externally rotated
Radiographs: are indicated in any patient in whom a shoulder dislocation is suspected
Associated conditions
Treatment:
Clavicle FracturesPatient 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)
Classified based on location (medial third, middle third, and lateral third)
Physical exam:
Radiographs: anteroposterior and clavicle view Treatment:
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| Soft tissue injuries of the shoulder |
AC Joint SeparationPatient 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
Biceps TendonitisPatient 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
Yergason’s test:
Rotator cuff tendinopathy/tearPatient 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.
Four Muscles of the rotator cuff: Rotator cuff inflammation/impingement:
Supraspinatus tear or inflammation:
Subscapularis tear or inflammation:
Teres minor/infraspinatus tear or inflammation:
Adhesive Capsulitis - AKA frozen shoulderPatient 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.
ImpingementPatient 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.
Shoulder BursitisPatient 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.
Glenohumeral joint OsteoarthritisPatient 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. |
Disorders of the Forearm, Wrist and Hand
Picmonic|
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| Fractures and dislocations of the forearm, wrist and hand | |
Greenstick Fractures
Torus (Buckle) Fractures
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Upper Arm |
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| 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. |
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 Humerus Fracture |
Elbow |
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| 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. |
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 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. |
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 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.
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%
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Forearm fractures |
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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) |
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Ulnar forearm fractures |
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| 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. |
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 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. |
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 Monteggia fracture |
Radial forearm fractures |
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Galeazzi fracture - Distal radial shaft fracture with dislocation of the ulnar-radial joint
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 Galeazzi Fracture |
Wrist Fractures |
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| Colles fracture - distal radial fracture
15-year old with "fall to an outstretched hand" now with acute onset, wrist swelling (view case)
Smith fracture - distal radial fracture
Scaphoid Fracture: fall on outstretched hand (SNUFFBOX tenderness) = treat as a fracture
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Hand Fractures |
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| Boxer's Fracture - Fracture at neck of 5th ± 4th metacarpal
13-year old with pain and edema over the 5th metacarpal (View Case)
 Treat boxer's fractures with an ulnar gutter splint with joints at least 60 degrees flexion Bennett's Fracture
Rolando's Fracture
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Medial Epicondylitis - GOLFER'S/PITCHER'S ELBOW
Lateral Epicondylitis - TENNIS ELBOW
Olecranon Bursitis - SCHOLAR'S ELBOW
Cubital Tunnel Syndrome - Ulnar Nerve Entrapment at the Elbow
Carpal Tunnel Syndrome Caused by a compression of the median nerve in the carpal tunnel
De Quervain's Tenosynovitis
Gamekeeper's Thumb - SKIER'S THUMB (ACUTE)
23-year old with acute onset, right thumb pain ReelDX (View Case)
 Can involve a partial or complete tear of the ulnar collateral ligament Dupuytren's Contracture – most often 4'th and 5'h digits
 an inherited proliferative connective tissue disorder that involves the hand's palmar fascia. Mallet (BASEBALL) finger - TEAR AT DIP JOINT
 Commonly associated with an avulsion fracture of the distal phalanx Boutonniere Deformity - TEAR AT PIP JOINT
 Tears at PIP joint causes inability to extend the finger resulting in hyperflexion at PIP Infections of the hand
Ganglion cyst
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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. |
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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. |
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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. |
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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. |
