Hand/Fingers
medial epicondylitis involves inflammation of the _____ muscle group tendon insertions, while lateral epicondylitis effects the ______ muscle group tendon insertions
A patient comes to you with a painless, large squishy bump on their wrist and is worried they might have a tumor. it transilluminates. What is it? Where on the wrist do most of these pop up?
Ganglion cyst
dorsal wrist
in a lateral elbow x-ray, the "sail sign" is an indicator of what?
Joint effusion (eg swelling or bleeding)
What is the most commonly torn rotator cuff tendon?
Supraspinatus
Differentiate valgus & varus
Valgus = distal portion is pointing away from midline of body
Varus = distal portion is pointing towards midline of body.
A skiier presents to the ski resort urgent care complaining of very intense thumb pain after sustaining a fall. You ask how he fell an he reports he fell on an oustretched hand with his ski pole, causing his thumb to get "stretched". He is very tender to thumb abduction and valgus stress of the 1st MCP joint. Particularly tender to palpation at the ulnar aspect of the 1st MCP.
What do you think are a couple of possible diagnoses? What do you want to do?
Likely a thumb UCL tear, maybe 1st Proximal phalanx or 1st metacarpal fx
Get an xray, rule out fracture. Often these ones present with an avulsion fracture of the proximal phalanx. If no fracture but high suspicion, MRI. If confirmed,
Conservative (partial tear and no fx/ nondisplaced fx) ->Thumb spica splint for a while then OT to regain motion. NSAIDs, RICE, lifting restriction
Surgery -> repair
Dequervain's tenosynovitis is inflammation of what? What is the common population affected?
inflammation of the 1st dorsal compartment (tendon sheath surrounding abductor pollicis longus and extensor pollicis brevis). Commonly affects mothers with young children from repeatedly picking them up.
Which splint would you choose?
Cockup wrist
Sugartong
Thumb Spica
Radial Gutter
wrist is to carpal tunnel syndrome as elbow is to ______
cubital tunnel syndrome.
Which nerves are involved for each?
An 81 year old patient who is not active at baseline presents with a moderately displaced humeral shaft fracture. First, What is particularly necessary to rule out? What is the most appropriate treatment?
A)Humeral shaft ORIF
B)Sarmiento Brace
C)Long arm posterior brace
D)Abduction sling
r/o neurovascular injury. these fx's are associated with radial nerve palsy causing wrist drop (unable to extend at the wrist).
B) sarmiento brace
In dupuytren's disease, what tissue thickens and causes contraction of the finger?
A)Palmar Aponeurosis
B)Flexor Retinaculum
C)Lumbricals
D)Opponens pollicis tendon
A) Palmar Aponeurosis
What are some signs of flexor tenosynovitis? Why is it a big deal?
Kavanel's signs
-Pain with passive extension
-held in Passive flexion
-pain with Percussion or palpation of flexor tendon sheath
and... - "sausage digit"
Can lead to necrosis/rupture of tendon and surrounding tissues
What is the most commonly fractured carpal bone? Where can it be palpated? What are some things that make treating this type of fracture tricky?
Scaphoid bone, palpated over anatomic snuffbox. Has retrograde blood flow, so proximal fragment has high chance of AVN. It also tends to not present obviously on XR right after the injury. If fx is displaced or necrotic tissue present, surgery. Conservative would be thumb spica splint +NSAIDs, activity modification, OT eventually, etc.
BoNuS: What are the borders of the anatomic snuffbox?
Differentiate a Galeazzi vs Monteggia fx
Monteggia: Proximal 1/3 ulna + radial head dislocation
Galeazzi: Distal 1/3 of Radius + DRUJ disruption
What are the 3 stages of adhesive capsulitis and their general timelines?
1)Freezing - progressively worsening pain and ROM, from 6 weeks-9 months
2)Frozen - Pain may improve at this stage but stiffness remains, ADLs (activities of daily living) become very difficult. 4-6 months
3)Thawing - Slow improvement in range of motion, lasting 6 months - 2 years.
extensor tendon is to mallet finger as flexor tendon is to _________
Jersey finger.
Boutonniere deformity puts the PIP/DIP in which positions? What is the root problem? How is this treated?
Boutonniere deformity arises from a central slip tendon tear (inserts on dorsal base of middle phalanx) -> PIP into flexion, DIP into extension.
Conservative: PIP extension splint x6wks then OT. Don't splint DIP otherwise it'll get stiff.
Surgery = Repair/Reconstruction
A patient presents to you with a 3 month history of numbness and tingling in her right hand. She complains of numbness primarily in her middle finger, but says her thumb and index finger can go numb at night occasionally. she has a recent EMG/NCS that she brought with her, confirming nerve entrapment at the wrist. What nerve is affected? What are some physical exam tests to evaluate? What are some treatment options?
Median nerve
Tests:
Tinel's sign: Tapping over carpal tunnel elicits numbness/shooting pain.
Durkan's test: Focal pressure over carpal tunnel produces symptoms within 30 seconds.
Phalen's test: Putting wrists together in flexion and holding produces symptoms within 60 seconds
Get EMG!
conservative tx:
-wrist braces (usually done at night)
-NSAIDs, activity modification, steroid injection (usually only done for gestational carpal tunnel syndrome)
-if all else fails, carpal tunnel release (cutting flexor retinaculum to open up carpal tunnel)
in simple elbow dislocations or nondisplaced extra-articular radial head fractures, what is the most important thing to do in treatment?
start moving it!!! start working with OT at ~7 days
With these injuries, its common to lose some extension of the elbow. Important to move early to prevent this.
In treatment of large, displaced SLAP tears of the labrum, what additional procedure is often added on, and why?
Biceps tenotomy/tenodesis. They cut the tendon of the long head of the biceps brachii away from its insertion on the supraglenoid tubercle, and reattach it at the intertubercular groove, just below the pec insertion. This prevents the biceps tendon rubbing against the SLAP tear, improving recovery times.
What is the etiology of trigger finger?
the A1 pulley (pulleys are fibrous bands along the volar side of fingers) can thicken and cause irritation of the tendon. Tendon can swell up and create nodules that get caught on pulley, causing the trigger sensation.
A common procedure for a rupture of the extensor pollicis longus tendon (EPL) is to transfer the tendon of the extensor indicis proprius (EIP) to the normal attachment site of the EPL. What finger actions are gained from this surgery and which are lost?
This is a surgery to regain thumb extension and abduction. Unfortunately we lose the ability to independently extend the index finger (eg. point) because the only tendons controlling the index finger are coming from Extensor Digitorum.
What are clenched fist views used for?
eval scapholunate rupture. with comparison to normal wrist, if pt's affected wrist has a wider gap b/t scaphoid and lunate, high likelihood -> get MRI.
a patient reports they have a history of a "bad elbow fracture". Upon exam, they have normal extension and flexion, but are not able to supinate much at all. Which is the most likely previous fracture?
A)Distal Humerus fracture
B)Radial head fracture, intra-articular, moderately displaced
C)Radial Neck fracture, non-displaced
D)Olecranon process fracture, significantly displaced
Your patient comes to you first thing in the morning because they said that while on the couch watching TV last night, they started having intense shoulder pain without any trauma or activity. She didnt sleep all night and you notice she's holding her arm very still. On x-ray, you notice what looks to be a bone-like structure superior to the humeral head. What is likely the issue?
Calcific Tendonitis.
Treat with steroid injection, microneedling, or surgery (get MRI for surg planning)
Differentiate bankart lesions and hill-sachs lesions
Related to shoulder dislocations.
Bankart lesions are fractures of the glenoid rim that chip off when the humerus dislocates
Hill-sachs lesions are triangular depression fractures of the humeral head from getting compressed against glenoid rim when dislocating.