Upper Extremity Disorders

What must be documented in shoulder dislocations?

• mechanism of injury

• exact time of injury

• if first dislocation

• numbness/tingling

• pulses intact

What shoulder dislocation are we worried about in patients with a hx of seizures?

posterior shoulder dislocation

What is another name for an acromioclavicular injury?

“Separated shoulder”

What is the typical mechanism of acromioclavicular injury?

Young person with direct fall onto shoulder

What pain pattern occurs in acromioclavicular injury?

Pain at the top of shoulder, radiates to the neck

What exam findings occur in acromioclavicular injury?

• Tender swollen AC joint

• Decreased ROM

• (+) Crossover test

• (+) AC Compression

How is acromioclavicular injury diagnosed?

• Clinical

• x-ray confirm

• Grading scale of injury (grade 1-3)

What is the treatment for acromioclavicular injury?

• Sling 2-4 weeks

• ice

• NSAIDs

• early ROM

• Significant displacement - surgery

Which type of shoulder dislocation is more common?

Anterior more common than posterior

What causes anterior shoulder dislocation?

significant trauma from fall or forceful throwing motion

What causes posterior shoulder dislocation?

less than 2% cases (seizures)

What sensation occurs in anterior shoulder dislocation?

Sensation of shoulder slipping out of joint when arm is abducted and externally rotated

How is the arm held in anterior shoulder dislocation?

Arm on affected side help by opposite hand in neutral position

What shoulder appearance occurs in anterior dislocation?

Acromion in prominent shoulder appears “squared off”

What test is positive in chronic anterior subluxers?

+ Apprehension test for chronic subluxers

When should x‑ray be obtained in anterior shoulder dislocation?

If unable to lift arm, get xray to confirm

Why is posterior shoulder dislocation frequently missed?

Frequently missed as on AP views it looks normal

What is the best view for diagnosing posterior shoulder dislocation?

Axillary view is best view for Dx

How is the arm held in posterior shoulder dislocation?

Arm on affected side is held adducted against chest and internally rotated

What physical finding occurs in posterior shoulder dislocation?

Posterior shoulder more prominent

What commonly causes posterior shoulder dislocation?

Often times due to seizure or electrocution

What imaging views are used in shoulder dislocation evaluation?

• AP

• Lateral

• Y views

• axillary

What is the treatment for shoulder dislocation?

Reduction ASAP, >1 hour IV pain medications, >2 hours general anesthesia

What should be reevaluated after shoulder dislocation?

neurovascular status

What confirms reduction of shoulder dislocation?

radiographs

What should be done if reduction is unsuccessful?

Immediate ortho consult

What should be done if reduction is successful without complication?

Ortho consult 3–5 days

What immobilization is used after shoulder dislocation?

Apply sling, Immobilize in neutral arm position for 4 weeks

What is impingement syndrome?

Rotator cuff tendonitis

What causes impingement syndrome?

Chronic, repetitive use

What is the progression of pain in impingement syndrome?

Pain begins as an inflammation → impingement → rotator cuff tear

What are symptoms of impingement syndrome?

• pain at greater tuberosity and lateral shoulder

• Pain and difficulty abducting arm

• (+) Neer and Hawkins sign

How is impingement syndrome diagnosed?

clinical

What is the treatment for impingement syndrome?

• Rest

• ice

• NSAIDs

• PT

• steroid injection

• acromioplasty

What causes a rotator cuff tear?

Injury from a fall, trauma, repetitive impingement, wear and tear

What are symptoms of a rotator cuff tear?

• Chronic shoulder pain

• night pain

• catching/grating when raising arm overhead

What exam findings occur in rotator cuff tear?

• Muscle atrophy

• In complete tear active abduction and forward flexion of shoulder is impaired

• (+) Drop arm and empty can tests

How is rotator cuff tear diagnosed?

MRI, ultrasound if unable to get MRI

What is the treatment for rotator cuff tear?

• Rest

• ice

• NSAIDs

• PT/OT

• consider surgery

What is biceps tendonitis?

inflammation of the long head of the biceps tendon and tendon sheath

What causes biceps tendonitis?

heavy or excessive lifting

What are symptoms of biceps tendonitis?

anterior shoulder pain, bicipital groove tenderness

What are the exam findings seen in biceps tendonitis?

• (+) Yergason's Test

• "popeye arm" if tendon rupture

How is biceps tendonitis diagnosed?

clinical

What is the treatment for biceps tendonitis?

• rest

• ice

• sling

• NSAIDs

• tenotomy

What is olecranon bursitis?

Swelling and inflammation of the olecranon bursa

What causes olecranon bursitis?

• Trauma

• prolonged pressure

• infection

• chronic dxs (gout, RA)

What symptoms occur in olecranon bursitis?

• Swelling

• pain

• redness and warmth – concern for infection

What ROM finding occurs in olecranon bursitis?

Reduced ROM if large enough or infected

How is olecranon bursitis diagnosed?

x-ray, aspiration fluid analysis

What is the treatment for olecranon bursitis?

• Surgery and ABX if infected

• Elbow pads

• activity modification

• NSAIDs

• corticosteroid injection

• Surgery if not improving (bursectomy)

What is lateral epicondylitis also called?

Tennis Elbow

What tendons are affected in lateral epicondylitis?

Extensor tendons

What causes lateral epicondylitis?

Repetitive wrist extension or supination

What exam finding occurs in lateral epicondylitis?

Point tenderness over the lateral epicondyle

What movement causes pain in lateral epicondylitis?

Pain with attempted extension of wrist against resistance (Cozen’s test)

How is lateral epicondylitis diagnosed?

Clinical

What is the treatment for lateral epicondylitis?

• Rest

• ice

• NSAIDs

• brace

• steroid injection

• surgery

What is medial epicondylitis also called?

Golfer’s or Pitcher’s Elbow

What causes medial epicondylitis?

Repetitive wrist flexion or pronation

What tendons are affected in medial epicondylitis?

Flexor tendons

What exam finding occurs in medial epicondylitis?

Point tenderness over medial epicondyle

What movement causes pain in medial epicondylitis?

Pain with attempted flexion of wrist against resistance

How is medial epicondylitis diagnosed?

Clinical

What is the treatment for medial epicondylitis?

• Rest

• ice

• NSAIDs

• stretching exercises

• steroid injection, surgery

What causes Gamekeeper’s Thumb?

Thumb forced into radial deviation

What ligament is stressed in Gamekeeper’s Thumb?

Stresses ulnar collateral ligament (ski pole)

What are the symptoms of Gamekeeper’s Thumb?

Pain or laxity with radial stress of thumb and deviation

How is Gamekeeper’s Thumb diagnosed?

Clinical – ulnar stress test

What is the treatment for Gamekeeper’s Thumb?

Thumb spica splint and cast or surgical repair

What causes de Quervain’s tenosynovitis?

Overuse to repetitive gripping causing inflammation of the extensor tendon sheath

What are the symptoms of de Quervain’s tenosynovitis?

pain along radial aspect of wrist

What test will be positive in de Quervain’s tenosynovitis?

(+) Finkelstein test

How is de Quervain’s tenosynovitis diagnosed?

Clinical

What is the treatment for de Quervain’s tenosynovitis?

• Rest

• NSAIDs

• thumb spica splint

• surgical release

What develops in the flexor tendon in trigger finger?

a nodule develops in the flexor tendon in the palm near the metacarpal head

What occurs when the tendon passes through the sheath in trigger finger?

audible or visible “pop or snap”

How is trigger finger diagnosed?

Clinical

What is the treatment for trigger finger?

• activity modification

• NSAIDs

• splint

• steroid injection

• surgical release

What is Dupuytren’s Contracture?

Thickened nodules overlying the flexor tendon on the ring finger/pinky finger near the distal palmar crease

What structure forms in Dupuytren’s contracture?

Fibrotic cord

What functional limitation occurs in Dupuytren’s contracture?

Limits finger extension

How is Dupuytren’s contracture diagnosed?

Clinical

What is the treatment for Dupuytren’s contracture?

• Splinting

• steroid injection

• surgical release

What is the most common benign tumor of the wrist?

Ganglion cyst

When do ganglion cysts commonly appear?

Appears commonly after injury

What are the symptoms of a ganglion cyst?

• soft

• painless

• fluid-filled mass usually on dorsal surface of wrist

What physical exam finding is seen in ganglion cyst?

Transilluminate

How is a ganglion cyst diagnosed?

Clinical

What is the treatment for a ganglion cyst?

Wrist splinting, aspiration of mass, surgical removal

What causes carpal tunnel syndrome?

Develops from chronic, repetitive wrist flexion

What nerve is compressed in carpal tunnel syndrome?

Median nerve compression

What are the symptoms of carpal tunnel syndrome?

• numbness and nighttime pain in the thumb

• index, and middle finger

• Thenar atrophy

• (+) Phalen and Tinel sign

How is carpal tunnel syndrome diagnosed?

Clinical, EMG if unsure

What is the treatment for carpal tunnel syndrome?

• Nighttime splinting

• steroid injection

• surgery