Orthopedics - Upper extremity

Question	Answer
GHJ Subluxation or dislocations mostly occur	in anterior-inferior direction
MOI for A/I GHJ dislocation	ABD UE is forcefully ER leading to tearing of inferior GH lig, anterior capsule and possibly labrum
Incidence of Posterior GHJ dislocation	rare and with multidirectional laxity
MOI of Posterior GHJ dislocation	HADD and IR of GHJ
Complications of GHJ Dislocation	Hill-Sachs lesions, SLAP lesions, Bankart’s lesion, axillary nerve bruising
Compression fx of posterior humeral head is called	Hill-Sachs lesion
Tearing of SUPERIOR glenoid labrum from posterior to anterior (above the middle of the socket)	SLAP lesion, may also involve biceps tendon
Avulsion of anteroinferior capsule & inferior GH lig assoc with glenoid rim (below the middle of the socket)	Bankart’s lesion
PO precautions from GHJ D/L surgery	avoid apprehension position (F >90d, HABD >90d, ER to 80d)
GHJ instability characterized by	popping/clicking, repeated sublux of GHJ
Traumatic GHJ instability is common in	young throwing athletes
Atraumatic GHJ instability is common in	pts with congenitally loose CT around the shoulder
What Dx test is very effective in Dx labral tears?	MRI
PO GHJ Instability plan	Sling 3-4wk, at 6wk sport specific training, full fitness 3-4m
Labral tear characterized by	non-localized Sho pain, worsened by OH activities or HBB, weakness, instability, pain on resisted FLEX of biceps, anterior tenderness
Gold standard for ID of labral tear	arthroscopic surgery
Compression of NVB in thoracic outlet between bony and soft tissue	Thoracic outlet syndrome
What comprises NVB in thoracic outlet?	brachial plexus, subclavian a/v, vagus n, phrenic n, sympathetic trunk
Common areas of compression in TOS include	superior thoracic outlet, scalene triangle, clavicle/1st rib, PMinor/thoracic wall
Sx procedures for TOS	Cx rib removal, anterior/middle scalenectomy
Clinical tests for TOS include	Adson’s, Roos’, Wright’s, Costoclavicular
If Sx repair of impingement, pt should avoid	shoulder elevation >90d
Irritation between RTC & Greater Tuberosity or posterior glenoid/labrum	Internal or posterior impingement
Cause of bicipital tendonitis	mechanical impingement of the proximal tendon between anterior acromion & bicipital groove
Humeral neck Fx commonly occur in	older osteoporotic women with FOOSH
Greater Tuberosity Fx commonly occur in	middle age and elder adults related to fall on shoulder
Humeral Neck/Gtr tuberosity Fx require Sx or immobilization?	no, fairly stable. Needs early mobilization to prevent adhesions of capsule
Restriction in shoulder motion as a result of inflammation & fibrosis of the shoulder capsule	Adhesive capsulitis
Adhesive capsulitis usu assoc with	disuse following surgery, repetitive microtrauma, DM2
Restrictions in Adhesive capsulitis	ER > ABD > FLEX > IR
Sx of primary Impingement Stage 1	intermittent mild pain with OH activities, >35yo
Sx of primary impingement Stage 2	mild-mod pain with OH activities
Sx of primary impingement Stage 3	pain at rest or with activities, possible night pain, scapular/RTC weakness noted
Sx of RTC tears (full thickness)	classic night pain, weakness in ABD & ER, loss of motion
Sx of adhesive capsulitis	loss of motion in capsular pattern
Sx of anterior instability	apprehension with HABD & ER, slipping, popping, sliding, weak scapular stabilizers
Sx of posterior instability	slipping of humerus out the back, esp with FLEX & IR
Sx of multidirectional instability	looseness in all directions, most pronounced with carrying luggage or turning over in bed, +/- pain
Lateral epicondylitis is a chronic inflammation of	ECRB at proximal attachment to lateral epicondyle of humerus (tennis elbow)
PPT factors for lateral epicondylitis	repetitive wrist extension or strong grip with wrist extended
Medial epicondylitis is an inflammation of	Pronator teres & FCR tendons at medial epicondyle of humerus
PPT factors for medial epicondylitis	pitching, driving golf swings, swimming, strong hand grip, excessive pronation of the forearm
Complications of distal humeral Fx	loss of motion, myositis ossificans, malalignment, NV compromise, ligament injury, CRPS
Things important to remember in distal Humeral Fx	examine quickly for NV status esp radial n, vascular-Volkmann’s ischemia, growth plates in youth
Distal humeral fx has high incidence of	malunion
Lateral epicondyle Fx common in	young people
Most lateral epicondyle Fx require what to ensure absolute alignment	ORIF
Osteochondrosis of humeral capitellum	OCD of central or lateral capitellum or radial head
OCD of humeral capitellum caused by	repetitive compressive forces between radial head and humeral capitellum
OCD of humeral capitellum usu occurs in	adolescents 12-15yr
Localized avascular necrosis of capitellum leading to loss of subchondral bone with fissuring & softening of articular surfaces of radiocapitellar joint in kids 10yr and younger	Panner’s disease
Repetitive valgus stresses to medial elbow with OH throwing can lead to	Ulnar collateral ligament injuries
Clinical Sx of UCL injury	pain at medial elbow at distal insertion of lig, sometimes parasthesias in ulnar nerve
Focus of rehab for UCL injury	after pain and inflammation begin strengthening of elbow flexors
Inability to ABD arm >90d and pain in shoulder on ABD can be injury to what nerve?	Spinal accessory n
Pain on FLEX fully EXT arm, inability to FLEX fully EXT arm, winging at 90d FLEX can be injury to what nerve?	Long thoracic nerve
Pain on forward shoulder FLEX, Sho weakness, Pain with scap ABD or CL Cx ROT can be injury to what nerve?	Suprascapular nerve
Inability to ABD arm with neutral rotation can be injury to what nerve?	Axillary nerve
Weak elbow FLEX with forearm SUP can be injury to what nerve?	Musculocutaneous nerve
Causes of ulnar nerve entrapment	direct trauma to cubital tunnel, traction due to medial elbow laxity, compression due to thickened retinaculum or hypertrophy of FCU, recurrent subluxation, DJD affecting cubital tunnel
Clinical findings of Ulnar nerve entrapment	medial elbow pain, paresthesia in ulnar distribution
Median nerve entrapment occurs where	within pronator teres and under superficial head of flexor digitorum superficialis
Median nerve entrapment due to	repetitive gripping
Sx of Medial nerve entrapment	aching pain with weakness of forearm muscles and paresthesias in median distribution
Radial nerve entrapment occurs where & why?	posterior or interosseous nerve occurs in radial tunnel as a result of OH activities and throwing
Sx of radial tunnel syndrome	lateral elbow pain, pain over supinator muscle, paresthesias in radial nerve distribution
What type of dislocation most frequent at elbow?	Posteriolateral
Posterolateral elbow dislocations occur as a result of	elbow hyperextension from a FOOSH
Posterior dislocations of elbow frequently cause	avulsion Fx of medial epicondyle 2/2 traction of MCL
What complications occur with complete elbow dislocation?	Ulnar collateral lig rupture, anterior capsule rupture, LCL lig, brachialis muscle, wrist flexor or extensor muscle
Clinical sx of elbow D/L	rapid swelling, severe elbow pain, deformity
Sx of CTS	burning, tingling, pins and needles, numbness in median nerve distrib at night, + Tinel’s, + Phalen’s
Long term CTS causes	atrophy and weakness of thenar muscles and lateral two lumbricals
Inflammation of extensor pollicis brevis and abductor pollicis longus at 1st dorsal compartment	DeQuervain’s tenosynovitis
Cause of DeQuervain’s	repetitive microtrauma, 2/2 swelling during pregnancy
Sx of DeQuervain’s	pain at anatomical snuff box, swelling, decreased grip & pinch, + Finkelstein’s
Most common wrist fracture resulting from FOOSH	Colles’ fracture
Med tx of Colles Fx	immobilized 5-8wk
Complication of Colles Fx	median nerve compression with excessive edema
“Dinner fork” deformity	results from dorsal or posterior displacement of distal fragment of radius with radial shift of wrist/hand
Wrist Fx with distal fragment of radius dislocation in volar direction	Smith’s Fx
Characteristic deformity of Smith’s fx	Garden spade deformity
Carpal Fx commonly during FOOSH	Scaphoid
Complications of scaphoid fx	AVN of proximal scaphoid
Medical tx of scaphoid fx	Immobilized 4-8wk
Banding on palm & digit flexion contractures resulting from contracture of palmar fascia	Dupuytren’s contracture
Typically affected joints in Dupuytren’s	MCP and PIP of 4th & 5th digits. 3 & 4 digits in diabetics
Rupture of central tendinous slip of extensor hood leads to	Boutonniere deformity
Sx of Boutonniere deformity	MCP extension, DIP extension, PIP flexion
Boutonniere deformity common	following trauma or RA with degeneration of central extensor tendon
Contracture of intrinsic muscles of finger with dorsal subluxation of lateral extensor tendons	Swan neck deformity
Sx of Swan neck deformity	MCP flexion, DIP flexion, PIP extension
Swan neck occurs	following trauma or RA with dengeration of lateral extensor tendons
Ape hand deformity	thenar muscle wasting with 1st digit moving dorsally until in line with 2nd
Ape hand deformity results from	median nerve dysfunction
Mallet finger	rupture or avulsion of extensor tendon at insertion into DP, flexion of DIP results
Mallet finger occurs due to	trauma forcing distal phalanx into flexion
Gamekeeper’s thumb	sprain of UCL of MCP joint of thumb resulting in medial instability
When does gamekeeper’s happen	fall during skiing
Boxer’s Fx	Fx of neck of 5th metacarpal
Boxer’s Fx occurs	punching
Boxer’s Fx medical tx	2-4wk of immobilization