Upper Extremity Talk

Question 1

What is this?

Answer 1

Distal biceps tear

Question 2

1. What is the action of the biceps?
2. What deformity is associated with this?
3. What test helps dx this?
4. What kind of injury is this?
5. Indications for surgery? 3
6. At what point is the tendon strong enough to lift one lb?
7. Which part of the picture is the tendon and which is edema?

Answer 2

1. Bicep supinates more than flexes.
2. Popeye’s deformity
3. Hook test- lateral to medial through the anticubital fossa. theres only one this thats there
4. This is an enthesopathy
5. Indications for surgery to fix distal biceps tear:
   - laborer- screwdrivers, door handles,
   - Pain/cramps - popeye deformity
   - Cosmetic- girls or skinny guys
6. Steriods will weaken these. at the three months the tendon is strong enough to lift a 1lb
7. 2- white is water, edema. balled up stuff is biceps tendon

Question 3

What is this?

Answer 3

Question 4

Tennis/Golf Elbow

1. Histology?
2. What kind of collagen is this?
3. What parts of the elbow do each present on?
4. How should we examine it? 3
5. Imaging?
6. Tx? 3
7. If not getting better when do something else?

Answer 4

1. Angiofibromistic metaplasia: METAPLASTIC!
2. Type 1 collagen- looks like a rope under the microscope
3. Tennis is on the outside and golf on the inside

4.

• Feel it/reciprocate the pain
• Tennis -resisted wrist extension
• push down on the long finger
  5. don’t really need much imaging but possibly routine plain films
  6. TX:
• FIRST LINE tx- time and physical therapy 95%
• NSAIDs- metaplastic tissue does get inflamed
• Cortisone injections- fenestrate it- stimulate the body’s natural response- 3 shots
  7. If its not getting better after 6-9 months do something else

Surgery- 80%

Question 5

For soft tissue injuries such tennis elbow and tendonitis what steriod injection should we use?

Answer 5

use betamethasone

Question 6

What is this?

Answer 6

Olecranon Bursitis

Question 7

Olecranon Bursitis

1. Who gets this?
2. What is a bursa?
3. DDx? 3
4. Why shouldnt you drain it?
5. First line?
6. If you need to drain, Drain it where?
7. Indications for removal? 3

Answer 7

1. people who alternate from each elbow.
2. Bursa- fluid filled sac- but no room besides the liquid layer.
3. DD:
   - RA (thicker, have other dz processes, rice bodies),
   - septic bursitis,
   - lipoma
4. Made of fluid producing cells so if you drain it will come back.
5. COMPRESSION SLEEVE- keeps from irritating and helps drain: FIRST LINE especially for traumatic
6. drain right along the triceps, don’t do it on the big bump
7. Indications for removal:
   - Drain fails
   - Nerve damage
   - Infection

Question 8

What could be a complication with draining a olecranon bursitis?

Answer 8

Will turn into a chronic draining sinus. squamous cell carcinoma > chronic tissue necrosis!!!!

Question 9

What is this?

AKA?

Answer 9

1. Radial/Ulnar Nerve palsies
2. saturday night palsies- pass out on their arm

Question 10

1. What does the radial nerve innervate for motor?
2. Sensory?
3. What will the hand look like?

Answer 10

1. Radial nerve - extensors-
2. sensation to first dorsal web space

Question 11

1. What does the ulnar nerve supply for motor?
2. What can you do for PE?
3. What will a palsie make the hand look like?

Answer 11

1. Ulnar- flexion/deviator -ab/adduction of the hand. little bit of clawing on the pinky
2. Push on the pinky

Question 12

What are the 4 sites of compression for the ulnar nerve/cubital tunnel (2nd most common nerve compression)?

Answer 12

There are five principal locations where the ulnar nerve may be compressed around the elbow:

1. Two heads of the Felxor Carpi Ulnaris
2. medial intermuscular septum
3. cubital tunnel
4. Guyon’s canal

Question 13

Where do we always need to palpate for ulnar palsies?

What tests? 3

Answer 13

1. ALWAYS NUMB HERE- push here.

2.

• Tinel’s sign.
• Phalen’s sign- hold their elbow up. 10 seconds to a minute. Minute and a half then its probably not too bad.
• May also be able to feel the nerve dislocate

Question 14

Indications for fixing the ulnar nerve palsie?

4

Causes? 2

Answer 14

Indications for fixing

1. Sublexation/dislocation
2. persistant numbness
3. instability- can feel nerve clicking
4. muscle atrophy

Causes?

1. Arhtritis,
2. osborns ligament pathology

Question 15

Where is the site of impingement for Carpal Tunnel/Median Nerve?

Answer 15

Question 16

1. What does the medial nerve supply sensation to? 2
2. How will they complain?
3. Where should we tap for stimulation?
4. What motor actions will they not be able to accomplish?

Answer 16

Most common peripheral nerve compression neuropathy

1.

• radial three digits
• +/- the ring finger-
  2. they will say the whole hands numb besides the small finger.
  3. Distal the the site of impingement - tap right here for stimualtion
  4. Thenar muscle- won’t be able to palmarly adduct. Push against my thumb.

Question 17

Carpal Tunnel/Median Nerve

1. The blood supply gets cut off and that’s why they have symptoms?3
2. What dz is associated with median nerve compression?
3. What test?
4. First line tx?
5. 2nd line?
6. 3rd line?

Answer 17

1.

• Inflammation/tendonitis
• Arthririts
• (less commonly fractures)
  2. Diabetes- associated with peripheral nerve compression because of the glycosylation- gets thicker
  3. Modified phalens- take fingers and push on carpal tunnel and then bend and squeeze
  4. TX;
• NSAIDS/aleve, with PPI
• Go get a splint (night time) > make sure hand is straight and not extended back.
  5. 2nd line: cortisol
  6. 3rd line: carpal tunnel release- indications: muscle wasting, persistent numbness.

Question 18

Dupuytren’s Syndrome

1. Histopathology?
2. Most commonly what?
3. Cause?
4. Can also go where? 2
5. How can we differentiate this from trigger finger?
6. Tx? 4
7. Can present in the hand how?

Answer 18

1. Histopathological- myofibrosis contracture
2. most commonly the ring finger
3. genetic

4.

• can also get this in the feet/lederhosens
• bent penis- peyronie’s
  5. Cord is superficial in the picture makes it not a trigger fingers but Dup
  6. Tx: If you can get it flat on a table then dont need to refer

If not send to Ortho

• splinting does work- will necrose if you need pulling
• needle (cut cord)
• Traditional open palmar fasectomy*****
• collagenous- Zyflex- clostridium toxin into hand
  7. Nodules and plaques in the hand

Question 19

1. What is a ganglion?
2. Filled with?
3. Describe how it keeps accumulating fluid?
4. DDx for bumps in the hand? 4
5. PE? 2
6. Who are more prone to get these?

Answer 19

1. A ganglion rises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.
2. Filled with synovial fluid- starts to push out
3. Creates a one way valve and comes out like a water tower
4. Bumps in the hand:
   - Ganglion
   - Lipoma
   - Schwannoma (can play like a guitar strip, not up and down but back and forth)
   - AV malformation
5. you can transilluminate, compressible
6. People with arthritis are more prone to get ganglions

Question 20

What is this?

Answer 20

Arthritis

Question 21

1. Arthritis is what?
2. What is the extremely aggressive form of OA?

Answer 21

1. inflammation of the joint because of loss of cartilage- osteoarthritis

cortisol

2. obliterans- crazy aggressive form of OA

Question 22

Describe Swan Neck and Boutonnieres

These occur with what?

Tx?

Answer 22

These are with tendon ruptures and lacerations

Swan neck injury is at the DIP joint

Boutonniere injury is at the PIP joint

Refer to ortho

Question 23

What do lumbercles do?

Answer 23

Lumbericle- flexes at your MP joints, and extends your IP joints

Question 24

1. What are the two flexors in the hand?
2. Which goes distal?
3. Which goes to the middle phalanx?
4. What is camper’s chiasm?

Answer 24

1. FDP and FDS are the two flexor tendons in the hand
2. deep goes distal- deep has a common muscle body-
3. FDS goes to the middle phalanx
4. crossing of the tendons, the passage of the tendons of the flexor digitorum profundus through the interval left by the decussation of the fibers of the tendons of the flexor digitorum superficialis

Question 25

What is this?

Answer 25

Mallet/ Jersy

Question 26

Mallet 1. Cause? Jersey 2. Cause?

Answer 26

1. tear of the tendon off the DIP 2. FDP off the middle finger = jersey finger

Question 27

1. What is a felon? 2. Tx? 2 3. DDx that you should watch for?

Answer 27

1. A felon is a fingertip abscess deep in the palm side of the finger. 2. - An early felon may be amenable to elevation, oral antibiotics, and warm water or saline soaks. - A more advanced felon requires incision and drainage. 3. herpetic whitlow- don’t drain that just makes it worse

Question 28

OT TALK What is the MOI for Mallet Finger?

Answer 28

Mechanism of injury is a hard hit to the distal end of the finger

Question 29

OT TALK Conservative Treatment of Mallet Finger

Answer 29

1. Splint the DIP joint in extension or slight hyperextension for 6-8 weeks 2. If they bend the DIP joint it starts the 6 weeks over 3. When the splint is discharged begin AROM at the DIP joint 4. Wear splint another 2 weeks at night

Question 30

Boutonniere Deformity 1. Most common MOI? 2. Can also be caused by? 2

Answer 30

1. Mechanism of injury is usually caused by a forceful blow to the bent finger 2. - It can also be caused by a cut to the top of the finger, which can sever the central slip from its attachment from the bone - It can also be caused by rheumatoid arthritis

Question 31

Conservative Treatment of Boutonniere Deformity 4

Answer 31

1. Splint the PIP joint in extension for 6-8 weeks leaving the DIP joint free 2. If they bend the PIP joint it starts the splint time over 3. Have them do active DIP flexion and extension several times throughout the day 4. When splint is discharged begin AROM to the PIP joint

Question 32

Thumb Ulnar Collateral Ligament Injury 1. AKA? 2. MOI? 3. Beware of what?

Answer 32

1. Also called skier’s thumb or gamekeeper’s thumb 2. Mechanism of injury is forceful blow radially to the thumb 3. Beware of Stener Lesion

Question 33

What is a stener lesion?

Answer 33

It occurs when the aponeurosis of the adductor pollicis muscle becomes interposed between the ruptured ulnar collateral ligament (UCL) of the thumb and its site of insertion at the base of the proximal phalanx. Cannot heal spontaneously If they have that little chip of bone may want to get a hand surgeon to look at it

Question 34

Conservative Treatment of UCL Injury 3

Answer 34

1. Hand based thumb spica splint for 6 weeks 2. Can remove to shower just don’t put lateral force on the thumb 3. At 6 weeks begin ROM

Question 35

Carpal Tunnel Syndrome 1. Caused by? 2. Symptoms?

Answer 35

1. Carpal tunnel is caused by compression of the median nerve in the carpal tunnel 2. Symptoms are numbness in the thumb, index, middle, and the radial side of the ring finger

Question 36

Conservative Treatment of Carpal Tunnel Syndrome 4

Answer 36

1. Night splinting. May splint in the day if symptoms are severe 2. NSAIDs 3. Stretching and nerve guides 4. Ergonomic instruction/Behavior modification

Question 37

Cubital Tunnel Syndrome 1. Caused by? 2. Symptoms are?

Answer 37

1. Cubital tunnel is caused by compression of the ulnar nerve in the cubital tunnel 2. Symptoms are numbness in the ulnar side of the ring and small finger

Question 38

Conservative Treatment of Cubital Tunnel Syndrome

Answer 38

1. Night splinting the elbow in extension. 2. NSAIDs 3. Stretching and nerve guides 4. Ergonomic instruction/Behavior modification

Question 39

Lateral Epicondylitis 1. AKA? 2. Symptoms are? 3. Pain with?

Answer 39

1. Also called tennis elbow 2. Symptoms are pain at the lateral elbow. 3. Pain with resisted wrist extension and supination.

Question 40

Conservative Treatment of Lateral Epicondylitis 4

Answer 40

1. Passive stretches for the wrist extensors 2. NSAIDs 3. Counter force brace 4. Ergonomic instruction/Behavior modification