Upper Extremity Disorders

Question 1

Distal Biceps tear:
deformity known as? 
Fxn of biceps? 
Test? 
Indications to fix?

Answer 1

• popeye deformity (muscle bunched up - distally not attached)
• biceps: primarily supinates, also flexes (along w/ brachioradialis)
• test: hook test (feel the tendon)

indications to fix:

• laborer (turn things - screwdriver)
• popeye - pinches
• cosmetic

Question 2

What is tennis/golf elbow? Presentation?
PE?
Tx?

Answer 2

• metaplastic change to tissue due to repetitive pronation of forearm and excessive wrist extension (tennis - lateral epicondylitis), golfers - medial epicondylitis
• presentation: tennis: lateral elbow pain esp w/ gripping, forearm pronation and wrist extension against resistance
  golf: tenderness over medial epicondyle, worse w/ pulling motion, worse w/ wrist flexion against resistance
• on PE:
  if tennis: resistance of extension of hand, don’t need further w/u unless trauma, get X-ray if worried about arthritis
• tx:
  ibuprofen (metaplastic tissue gets pulled on and becomes inflamed) - doesn’t reverse metaplasia
  injectable steroids (beta-methasone), time and therapy (biggest tx) - stretch and strengthening

Question 3

What is olecranon bursitis?
Presentation?
PE?
Tx?

Answer 3

• inflammation over bursa
• etiology: gout, inflammation, direct trauma (repetitive, microtrauma) - cont leaning on elbows
• clinical manifestations: abrupt swelling (boggy, tender, red elbow), limited ROM w/ flexion, eval for skin breaks to r/o sepsis
• Tx: if drain most likely will come back (augment w/ abx), if traumatic don’t drain - can turn into chronic drainage (can lead to squamous cell carcinoma)
• compression sleeve - helps drain, helps w/ irrigation
• take out bursitis if interfering w/ ulnar nerve or infected

Question 4

Radial nerve palsy:
How common
presentation
Tx?

Answer 4

• uncommon, easy to ID, called saturday night palsy (pass out after drinking on arm - have numbness on back of hand)
• have wrist drop, can’t extend wrist or fingers
  tx: watch it, reer to ortho

Question 5

Ulnar nerve palsy:
What is affected? 
Tests?
indications to fix?
Tx?

Answer 5

• flexors and ulnar deviation affected - numbness in last 2 fingers that is worse w/ elbow flexion
• test: abduction and adduction (Wartenburg - push in on pinky, have pt resist, pinky will want to abduct), froments : thumb lifted up w/ paper in hand (weakness in adductor pollicis, flexor pollicis brevis)
• indications to fix:
  subluxation of ulnar nerve, numbness throughout the day, instability, muscle atrophy
• tx: wrap in dish towel, or volleyball kneepad, sleep w/ arm straight

Question 6

Where are the 5 sights of compression of ulnar nerve?

Answer 6

• cubital tunnel - MC spot (2nd most common neuropathy after carpal tunnel) - have + Tinnels sign and phalens at elbow
• intramuscular septum
• 2 heads of flexor carpi ulnaris
• guyons canal (near the wrist)

Question 7

What is the MC peripheral nerve neuropathy? What will pt complain of?

Answer 7

• carpal tunnel syndrome
• pt will complain of whole hand going numb except for pinky, feel weak distal to sight of impingement, won’t be aple to palmarly adduct w/ thumb

Question 8

RFs for carpal tunnel? Clinical manifestations?

Answer 8

• DM big RF
• clincal manifestations: parasthesias and pain in first 3 + or - 4th finger esp at night (b/c of normal flexion of wrist during sleep), weakness in thumb, increased pain” at night, repeated flexion/extension of wrist, decreased pain: shaking hands

Question 9

Dx of Carpal tunnel syndrome? Management? What can carpal tunnel mimic?

Answer 9

dx:

• tinel’s sign
• phalens sign: for 30-60 sec reproduces sxs, EMG

management:
volar splint, NSAIDs, corticoisteroids, surgery in refractory cases

• indications for carpal tunnel release:
  muscle atrophy and chronic numbness
• can mimic C6 - feel numbness, pain up arm but past elbow

Question 10

What is Dupuytren’s syndrome? Tx?

Answer 10

• predominately found in N. Europeans, MC in men 40-60
• its thickening of palmar fascia (superficial to tendons), especially common at ring and pinky finger, nodules often painful
• histopath: myofribrous contracture
• genetic: also can get in feet (Lederhosen) and penis (peyronies)

tx:

• refer to ortho, or just follow if not bothersome
• needle aponeurotomy
• open palmar fasciatomy (gold std) - surgically excise
• collagenase (xiaflex) - clostridium toxin

Question 11

What are ganglions? DDx? Tx?

Answer 11

• filled w/ synovial fluid at jt, a rent forms (weakening in jt capsule: fluid builds and creates a one way valve)
• DDx:
  lipoma
  schwanoma
  AV malformation
• if ganglion will transilluminate, if schwanoma look dark, positive tinel’s, can’t move proximally or distally just side to side, if AV malformation will see vessels upon transillumination, lipoma will transilluminate but will feel more rubbery

tx:

• observation
• immobilization - brace or splint
• aspiration: if causes great deal of pain or limits activities (fluid can be drained)
• surgery if all else fails

Question 12

Arthritis:

presentation? Tx?

Answer 12

• osteophytes, loss of cartilage, bone spurs from inflammatory cascade
• in OA: won’t deviate to ulnar side like RA, affects DIP jts (heberden’s nodes)
• osteo-obliterans: total erosion of jt
• tx: anti-inflammatories (Tylenol in elderly if at risk for bleeding), splints, activity modification, steroid injections
• jt replacements - final tx

Question 13

What is a swan neck deformity?

Answer 13

-have extended PIP and flexed DIP

Question 14

What is a boutonniere deformity?

Answer 14

• sharp force against tip of partially extended digit - leads to hyperflexion of PIP and extended DIP (disruption of extensor tendon at base of middle phalanx)

Question 15

How do you diff b/t profundus and superficialis muscle damage?

Answer 15

• profundus goes deep (flexes distal interphalangeal jt)
• superficialis flexes proximal interphalangeal jt
• profundus distinctly flexes DIP and indirectly flexes the PIP
• Can assess superficialis - have pt immobilize all fingers besides 1 being tested, prevents profundus from indirectly flexing PIP, and then instruct pt to flex - if finger if FDS intact - pt will flex at PIP jt
• to assess profundus: have pt extend digit, grab finger to immobilize PIP and MCP jts - instruct pt to flex finger - if profundus intact - pt will flex at DIP jt

Question 16

What is a jersey finger?

Answer 16

• AKA rugby or sweater finger - describes a type of injury where there is avulsion of the FDP at the base of the DIP
• MC affects 4th digit
• sudden hyperextension of actively flexed finger (grabbing jersey during football)
• going to have slight extension at DIP, pain and tenderness over jt
• conservative tx

Question 17

What is a mallet finger?

Answer 17

• tear of tendon distally (DIP) - disruption of extensor mechanism of finger at DIP - can be avulsion bony injury or just tendinous
• occurs in volleyball/bball (motion such as jamming your finger)
• characterized by inability to extend finger at DIP, slight flexion at this jt
• can lead to swan neck deformity and secondary osteoarthritic changes

Question 18

Presentation of scaphoid fracture?

Answer 18

• MOI: FOOSH on extended wrist, MC carpal fx
• snuff box tenderness
• tx as fracture, put in splint, re-image in 2 wks (don’t want AVN)

Question 19

When should you refer on phalanx fractures?

Answer 19

• whenever articular surface involved