PANCE Blueprint Musculoskeletal (8%)

Upper extremity disorders (PEARLS)

Disorders of the shoulder

Shoulder Fractures/dislocations

Shoulder Fractures

  • 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

Treatment:

  • 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

Treatment:

  • 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 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 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/tearrotator-cuff

  • 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

  • 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

Impingement

  • 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

  • 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

  • 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

  • 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): posterior 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

Elbow 

Supracondylar fracture

  • Usually, occurs from fall to an outstretched hand
  • X-ray: ANTERIOR fat pad sign = dark area 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

  • 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

  • Common upper extremity injury in infants and young children
  • Generally, occurs with a pulling upward type of motion while the child has an outstretched arm
  • Child refuses to move arm on presentation
  • Always ensure the child spontaneously uses the arm after reduction before discharging to confirm success
  • Be open to referred pain (wrist pain possible here, elbow pathology diagnosed)
  • TX: The supination-flexion technique is the classic method of reducing a subluxed radial head. It has a success rate of 80-92%.

Forearm fractures

radius-and-ulnar-fracture

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

Ulnar forearm fractures

Nightstick fracture - Isolated fractures of the ulna, typically transverse and located in the mid-diaphysis and usually resulting from a direct blow.

Nightstick Fracture

Monteggia fracture - Proximal ulnar shaft fracture with radial head dislocation

  • 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 

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

bennett-rolando

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)
  • ULNAR COLLATERAL LIGAMENT INJURY OF THUMB
  • 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 - AKA Claw hand – 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
460px-Morbus_dupuytren_fcm

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

Mallet (BASEBALL) finger - TEAR AT DIP JOINT

  • 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

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