UPPER EXTREMITY

Question 1

function of biceps brachii

Answer 1

supination of forearm

flexion at elbow

Question 2

function of brachialis muscle

Answer 2

flexion at the elbow

Question 3

test if concerned for bicep rupture

Answer 3

hook test - hook at elbow with fingers, then pronate/supinate - won’t feel bicep if ruptured

Question 4

TENNIS ELBOW

Answer 4

lateral epicondylitis

• inflammation of tendon insertion of ECRB (extensor carpi radialis brevis muscle) due to repetitive pronation of forearm and excessive wrist extension
• Lateral elbow pain - especially with gripping, forearm pronation, and wrist extension against resistance
• radiates down forearm, or worsens when lifting objects with forearm prone

TREATMENT = RICE, NSAIDS, PT, brace

• can do intraarticular steroid injection
• surgery if failure of conservative management

Question 5

GOLF ELBOW

Answer 5

medial epicondylitis

• inflammation of pronator teres-flexor carpi radialis due to repetitive stress and tendon insertion of flexor forearm muscle

MC in golfers, and patients who do household chores

• tenderness over medial epicondyle that is worse with pulling activities - reproduced with wrist FLEXION against resistance

TREATMENT = RICE, NSAIDS, PT, brace

• can do intraarticular steroid injection
• surgery if failure of conservative management

Question 6

treatment of __________ epicondylitis is more difficult

Answer 6

medial

Question 7

angiofibromatous metaplasia

Answer 7

epicondylitis

guest speaker says epicondylitis is not actually inflammation, but that the tendinous fibers are being replaced with angiofibromatous tissue

so steroid injections are for pain, not for the inflammation (because not actually inflamed!)

Question 8

test for tennis elbow

Answer 8

“resistant wrist extension” - arm straight out, resist the pt trying to extend their wrist upwards

Question 9

test for golfers elbow

Answer 9

resistant wrist flexion

Question 10

OLECRANON BURSITIS ETIOLOGIES

Answer 10

⦁ gout
⦁ inflammation
⦁ direct trauma (repetitive, microtrauma)
⦁ infection

Question 11

OLECRANON BURSITIS

Answer 11

• inflammation of bursa over bony prominences
• potential space or sac, but isn’t fluid filled (bursitis = then gets filled with fluid)
• more common in men
• can drain as long as its not infected, but if you try to drain out, now have a connection to outside world - can now get infected. fluid will continue to drain and drain
• so if you want to drain it = have to drain it from above

TREATMENT = NSAIDS & compression; the body will naturally absorb the fluid; don’t have to treat

Question 12

clinical manifestation of olecranon bursitis

Answer 12

• abrupt “goose egg” swelling - boggy/red elbow
• can be tender or painless
• limited ROM with flexion
• evaluate for skin breaks (to rule out septic bursitis)

treatment = rest, NSAIDS, compression, can do steroid injections. avoid repetitive motions

Question 13

RADIAL NERVE PALSY

Answer 13

• radial nerve comes off the brachial plexus - starts in back / neck / shoulder –> triceps –> antecubital fossa –> down forearm to thumb region
• can occur when you fall asleep on nerve for too long
• get paralysis (temporary) of the thumb extensor, wrist extensors, and triceps
• the radial nerve innervates the back of the first web space
• the median nerve innervates the thumb, index, middle and 1/2 of the ring finger

PARSONAGE TURNER SYNDROME = radial nerve palsy after a cold (URI)

Most radial nerve palsies get better on their own

Question 14

most common site for compression of ulnar nerve –> ulnar nerve palsy

Answer 14

cubital tunnel of the elbow

Question 15

radial nerve palsy after a cold

Answer 15

parsonage turner syndrome

Question 16

ulnar nerve is what allows finger _________

Answer 16

adduction - putting fingers together - so do froment test

Question 17

FROMENT’S SIGN

Answer 17

for ulnar nerve palsy
make an OK sign with thumb and index finger

adducting fingers = difficult with ulnar nerve palsy - weakness = have weakness of pinch grip

Question 18

WARTENBURG SIGN

Answer 18

for ulnar nerve palsy

lay hand down flat - pinky will abduct away

Question 19

WARTENBURG SIGN

Answer 19

for ulnar nerve palsy

lay hand down flat - pinky will abduct away

Question 20

ulnar nerve palsy tests

Answer 20

paper test - froment’s sign
wartenburg sign
can do tinnel’s at elbow (tap)
can hold flexion at elbow - pinches off ulnar nerve

Question 21

• median nerve entrapment / compression

Answer 21

CARPAL TUNNEL

Question 22

increased incidence of carpal tunnel with

Answer 22

diabetes

Question 23

CARPAL TUNNEL SYNDROME

Answer 23

• median nerve entrapment / compression at carpal tunnel
• increased incidence with DIABETES
• paresthesias / pain of first 3 digits and 1/2 of ring finger - especially at night - due to normal wrist flexion during sleep
• pain may radiate to neck, shoulder, chest
• Thenar muscle wasting is seen if advanced

CLINICAL MANIFESTATIONS

• paresthesias / pain in thumb/index/middle and 1/2 of ring finger
• worse at night*****
• increased pain with repeated flexion of wrist
• decreased pain when shaking hands

DIAGNOSIS

• Tinel’s sign
• Phalen’s sign
• modified Phalen’s = better = flex at wrist, just like with Phalen’s, but compress median nerve at same time

TREATMENT = volar splint + NSAIDS. Steroid injections. May need surgery in refractory cases

Question 24

CLINICAL MANIFESTATIONS OF CARPAL TUNNEL SYNDROME

Answer 24

• paresthesias / pain in thumb/index/middle and 1/2 of ring finger
• worse at night*****
• increased pain with repeated flexion of wrist
• decreased pain when shaking hands

feels better when arm held down - increased blood flow; carpal tunnel pressure is inhibiting blood flow to median nerve

• pain may radiate to neck, shoulder, chest
• Thenar muscle wasting is seen if advanced

Question 25

TESTS FOR CARPAL TUNNEL

Answer 25

- Tinel's sign (tap on median nerve) - Phalen's sign (praying mantis) - modified Phalen's = better = flex at wrist, just like with Phalen's, but compress median nerve at same time

Question 26

TREATMENT FOR CARPAL TUNNEL

Answer 26

volar splint - make sure STRAIGHT SPLINT - worn at night - NSAIDS - steroid injection - surgery in refractory cases

Question 27

DUPUYTREN'S CONTRACTURE

Answer 27

- most often confused with trigger finger - thickening of palmar fascia - can't move ring finger (vs trigger finger = cogwheeling of finger) Most common in men 40-60 RISK FACTORS - genetic predisposition: Northwestern Europeans - Alcohol abuse - diabetes - Contracture of the palmar fascia due to nodules/cords --> fixed flexion derformity at the MCP - especially seen in the ring finger, and pinky finger - have nodules over the distal palmar crease or proximal phalanx - nodules are often painful **Fixed flexion deformity at MCP joint Treatment = intralesional steroid injections, collagenase injections, PT - can do surgical correction if contracture is > 30 degrees at MCP joint, or if any PIP contracture

Question 28

RISK FACTORS FOR DUPUYTRENS

Answer 28

Most common in men 40-60 RISK FACTORS - genetic predisposition: Northwestern Europeans - Alcohol abuse - diabetes

Question 29

which fingers mostly affected by Dupuytren's contracture

Answer 29

ring & pinky fingers

Question 30

dupuytren's treatment

Answer 30

intralesional steroid injections, collagenase injections, PT - can easily perform surgery to correct contracture - Xiaflex = new medication - injection that breaks down collagen in the fascia

Question 31

GANGLION CYST

Answer 31

- joint fluid leaks into cyst - don't drain these! will continuously drain (like bursa) and lead to infection - need to completely excise it and cauterize it to fully go away to where it won't fill back up - can diagnose with transillumination (can also aspirate fluid to test it, or ultrasound) Form in the presence of joint or tendon irritation or mechanical changes; occur in patients of all ages. May change in size or disappear completely. May or may not be painful - not cancerous, and don't spread Treatment = don't drain these! will get infected. Surgery if bothersome. If asymptomatic = don't need to do anything

Question 32

Swan Neck & Boutonniere deformity = characteristics of

Answer 32

RA

Question 33

Swan neck

Answer 33

flexion at DIP | hyperextension at PIP

Question 34

Boutonniere's deformity

Answer 34

hyperextension at DIP | flexion at PIP

Question 35

differentiation for swan neck vs boutonniere's is important because of

Answer 35

treatment approach