1 00:00:01,560 --> 00:00:05,360 Okay, so let's do a CRAM session for MSK upper extremity. As always, 2 00:00:05,360 --> 00:00:07,280 I'm going to stick to the need to know stuff. I'm not going 3 00:00:07,320 --> 00:00:10,199 to bother your time with the stuff that I really feel is very low yield 4 00:00:10,199 --> 00:00:12,640 and that you don't need to know. So let's go ahead and get started. 5 00:00:12,679 --> 00:00:15,160 As always, thank you so much for the really nice comments. You 6 00:00:15,160 --> 00:00:18,519 guys are just the nicest people, So thank you so much. Let's go 7 00:00:18,559 --> 00:00:22,480 ahead and start with the shoulder and they'll work our way down. So anterior 8 00:00:22,519 --> 00:00:27,079 gleno humeral dislocation, so this is your most common type. Anterior dislocation is 9 00:00:27,120 --> 00:00:31,160 going to account for around ninety five to ninety seven percent of cases of shoulder 10 00:00:31,199 --> 00:00:34,439 dislocations. Now, as far as the mechanism of injury, it's going to 11 00:00:34,479 --> 00:00:39,200 be a blow to the abducted, externally rotated and extended arm. So that's 12 00:00:39,240 --> 00:00:43,079 the most common mechanism of injury. So think like blocking a basketball shot your 13 00:00:43,159 --> 00:00:45,719 arms up and out. Less commonly is going to be a blow to the 14 00:00:45,719 --> 00:00:50,920 posterior humorous or a fault on an outstretched arm can also cause an anterior dislocation, 15 00:00:50,960 --> 00:00:54,719 but focus on that arm being abducted. Abducted away from the body, 16 00:00:55,000 --> 00:00:58,359 extended and externally rotated, and then something hitting the arm in that position. 17 00:00:58,679 --> 00:01:02,359 Non physical exam. You need to know that you're looking for an abducted, 18 00:01:02,399 --> 00:01:07,799 abducted externally rotated arm, So an anterior dislocation of the shoulder causing the arm 19 00:01:07,840 --> 00:01:12,000 to be slightly abducted and externally rotated. Diagnosis, you're going to do an 20 00:01:12,079 --> 00:01:15,480 X ray. X ray of the shoulder is normally going to be enough to 21 00:01:15,480 --> 00:01:19,040 diagnose. Going to get an ap view, scapular y view, axillary view. 22 00:01:19,000 --> 00:01:23,599 A few associated injuries you should know with an anterior dislocation. There's the 23 00:01:23,680 --> 00:01:29,400 hill Sacks, bank art lesions, axillary nerve injury. It wouldn't go crazy 24 00:01:29,439 --> 00:01:33,680 memorizing the specific injuries what they involved. Just know they're associated with anterior dislocation 25 00:01:34,239 --> 00:01:38,159 hill sacks real quick. It's a cortical depression. Hill sax lesion is a 26 00:01:38,200 --> 00:01:42,359 cortical depression in the humoral head made by the glenoid rim. Bank art legions 27 00:01:42,359 --> 00:01:47,519 occur when the glenoid labrim is disrupted during the dislocation, and a bone fragment 28 00:01:47,560 --> 00:01:51,040 is a vols and an axillary nerve injury. This one's probably the most important 29 00:01:51,079 --> 00:01:55,359 associated injury to know. So it's really important to assess the nerve vascular status 30 00:01:55,400 --> 00:01:59,799 in patients with an anterior shoulder dislocation because axillary nerve disfunction can actually show up 31 00:01:59,799 --> 00:02:02,359 to up to forty two percent of patients with an anterior dislocation. So you're 32 00:02:02,359 --> 00:02:06,840 gonna look for a loss of sensation on what's called the shoulder bags distribution. 33 00:02:07,079 --> 00:02:09,080 It's basically like on a cop uniform or a military uniform. Just think of 34 00:02:09,080 --> 00:02:12,400 the area of the arm that the shoulder badge would be. Where they have 35 00:02:12,400 --> 00:02:15,039 a badge on the arm. That's where the axillary nerve innervates, and that's 36 00:02:15,039 --> 00:02:17,960 where they may have this loss of sensation. They may also have deltoid muscle 37 00:02:17,960 --> 00:02:23,439 weakness. So just be familiar that axillary nerve dysfunction is common in anterior dislocations. 38 00:02:23,800 --> 00:02:27,680 As far as treatment reduced in sling, there's not much to know here, 39 00:02:27,800 --> 00:02:30,759 certainly nothing to memorize. You reduce the dislocation, mobilize it with the 40 00:02:30,800 --> 00:02:35,199 sling, and then assess for axillary nerve dysfunction pre and post reduction. Okay, 41 00:02:35,199 --> 00:02:38,800 so there's a lot of random things to know for anterior dislocations. So 42 00:02:38,840 --> 00:02:42,680 the way that you're going to remember them is by remembering a guy named Antonio. 43 00:02:42,759 --> 00:02:45,800 So this is visualization times is much easier on the YouTube channel. I 44 00:02:45,800 --> 00:02:49,120 have a nice little picture I'm made in MS paint, but let's just try 45 00:02:49,120 --> 00:02:53,520 to visualize this. So Antonio is this guy and in one hand he's holding 46 00:02:53,879 --> 00:02:58,000 a picture and in the other hand he's holding an axe. The picture that 47 00:02:58,039 --> 00:03:00,319 he's holding is a bank on top of a hill like this nice pretty hill 48 00:03:00,360 --> 00:03:02,759 with a sunset in the background. And then there's a bank sitting on top 49 00:03:02,800 --> 00:03:07,159 of the hill. That's the picture. The other hand he's holding an axe. 50 00:03:07,280 --> 00:03:09,599 Now he's holding both of these up and out by his sides. His 51 00:03:09,759 --> 00:03:15,919 arms are abducted and they're externally rotated. So Antonio helps you to remember this 52 00:03:15,919 --> 00:03:21,000 as an anterior dislocation. Antonio anterior dislocation. The picture that he's holding with 53 00:03:21,039 --> 00:03:23,560 the bank on top of a hill helps you remember bank art lesions and hill 54 00:03:23,680 --> 00:03:29,840 sack lesions that can commonly be seen in anterior dislocations. And then the axe 55 00:03:29,840 --> 00:03:32,960 he's holding in his other hands helps you remember axillary nerve dysfunction that's the most 56 00:03:32,960 --> 00:03:37,000 common in anterior dislocations. And then finally, the position of his arms. 57 00:03:37,039 --> 00:03:40,039 Like I said, they're abducted and externally rotated. That helps you remember both 58 00:03:40,039 --> 00:03:44,919 the way the arms usually positioned during the physical exam and during the injury too. 59 00:03:44,919 --> 00:03:47,439 So remember a guy named Antonio holding a picture of a bank on top 60 00:03:47,479 --> 00:03:51,680 of a hill on one hand holding an axe, and the other both arms 61 00:03:51,680 --> 00:03:54,080 are abducted and externally rotated. And that should be all you need to know 62 00:03:54,080 --> 00:04:00,479 for anterior dislocations for the exam, moving onto posterior glenohumeral dislocation. So these 63 00:04:00,520 --> 00:04:03,840 are much less common compared to anterior They only occur in around two to four 64 00:04:03,879 --> 00:04:09,759 percent of patients. Mechanism of injury for anterior dislocations wasn't very high yield, 65 00:04:09,759 --> 00:04:13,800 but for posterior dislocations it is, and it's because it's unique. And if 66 00:04:13,800 --> 00:04:16,319 you listen to any of my other content, you always know anytime there's something 67 00:04:16,399 --> 00:04:18,920 unique, they're going to ask you questions about it, So keep that in 68 00:04:18,959 --> 00:04:25,199 mind. Mechanism for posterior dislocations is going to be seizure and electric shock, 69 00:04:25,319 --> 00:04:28,040 so those are the ones that you need to know. Of course, trauma 70 00:04:28,120 --> 00:04:30,560 like a blow to the anterior portion of the shoulder can cause a posterior dislocation, 71 00:04:30,839 --> 00:04:35,480 But what you should focus on is violent muscle contractions following a seizure or 72 00:04:35,480 --> 00:04:40,000 electrocution, because those are the unique components that they like to ask questions about 73 00:04:40,639 --> 00:04:44,560 seizure or electric shock. Remember those for your mechanism of injury in a posterior 74 00:04:44,600 --> 00:04:48,759 dislocation. Now physical exam opposite of anterior So for a posterior dislocation, it's 75 00:04:48,759 --> 00:04:54,240 going to be adducted and internally rotated. So usually the patient's going to hold 76 00:04:54,279 --> 00:04:59,959 their arm in adduction and internal rotation and is usually unable to externally rotate again. 77 00:05:00,000 --> 00:05:04,199 And that's different than anterior dislocations, which was abducted, abducted and externally 78 00:05:04,319 --> 00:05:08,720 rotated. Now, diagnosis, you're going to get an X ray, so 79 00:05:08,759 --> 00:05:12,839 you'll do your normal routine shoulder views, apyve you, etc. But be 80 00:05:12,920 --> 00:05:17,040 aware of the light bulb sign on posterior dislocations because they may ask about this. 81 00:05:17,399 --> 00:05:20,600 So on the AP view, the humoral head is going to be internally 82 00:05:20,680 --> 00:05:25,959 rotated and because of this, the twoberocities of the humorous they're not going to 83 00:05:26,000 --> 00:05:29,480 be visible. They're going to be normally, they're project out laterally, but 84 00:05:29,519 --> 00:05:32,360 they're not going to be visible because the humoral heads internally rotated. And because 85 00:05:32,399 --> 00:05:34,759 of this, I have to take my word for it, the humoral head 86 00:05:34,800 --> 00:05:39,560 kind of takes on the circular appearance and supposedly looks like a light bulb. 87 00:05:39,639 --> 00:05:42,439 I guess it kind of does. So anyways, if you hear a light 88 00:05:42,480 --> 00:05:46,079 bulb sign, be thinking. Posterior dislocation treatment is going to be the same 89 00:05:46,079 --> 00:05:49,360 as an interior You're going to reduce and sling. Okay, So for posterior 90 00:05:49,399 --> 00:05:54,879 dislocation, there's a few things that you need to know. Remember your caesar 91 00:05:55,279 --> 00:05:59,480 seizure and shock can be the mechanism of action, mechanism of injury. Remember 92 00:05:59,480 --> 00:06:02,639 the arm is likely going to be adducted and internally rotated. And remember the 93 00:06:02,800 --> 00:06:05,639 light bulb sign. Those are the high yel things. And the way that 94 00:06:05,680 --> 00:06:11,800 you remember that is I want you to visualize this warning on a poster board. 95 00:06:12,160 --> 00:06:15,079 So on the posterboard there's going to be a picture, and on the 96 00:06:15,120 --> 00:06:19,160 posterboard there's going to be a picture of a broken light bulb. There's going 97 00:06:19,160 --> 00:06:23,240 to be a finger, and then there's going to be a picture of a 98 00:06:23,279 --> 00:06:27,160 guy being shocked. And it says if you add your finger into a broken 99 00:06:27,240 --> 00:06:30,800 light bulb, you'll get shocked, So add an into if you add your 100 00:06:30,800 --> 00:06:35,000 finger into, that helps you remember adducted and internal rotation. So if you 101 00:06:35,040 --> 00:06:40,680 add your finger into adducted internal rotation, remember that's the most common presentation, 102 00:06:41,040 --> 00:06:44,319 the broken light bulb, because you remember the light bulb sign on X ray 103 00:06:44,360 --> 00:06:48,720 scene of posterior dislocations and shocked because remember the unique mechanism of injury, electric 104 00:06:48,720 --> 00:06:53,279 shock, and seizure. And then again this is all on a posterboard because 105 00:06:53,279 --> 00:06:58,600 that posterboard helps remember posterior dislocation. So again, remember a poster board, 106 00:06:58,639 --> 00:07:00,639 and on the poster board it says if you add your finger into a broken 107 00:07:00,720 --> 00:07:04,639 light bulb, you'll get shocked. Visual a posterboard with a finger a plus 108 00:07:04,639 --> 00:07:08,319 sign, a broken light bulb and a guy being shocked, and you'll remember 109 00:07:08,319 --> 00:07:12,560 everything you need to know for posterior dislocations. All right, moving on to 110 00:07:12,759 --> 00:07:15,000 a rotator cuff injury. This is definitely a high heel topic. There's a 111 00:07:15,000 --> 00:07:18,000 good deal to know for this, and you'll likely get a question on this. 112 00:07:18,519 --> 00:07:21,800 So let's go over a rotator cuff tears and impingement. So first, 113 00:07:21,839 --> 00:07:25,360 you need to know your muscles in the rotator cuff. I'm sure you've all 114 00:07:25,399 --> 00:07:30,959 heard of the famous mnemonic sits S I S so superspinatus infraspinatus tarifs minor and 115 00:07:31,000 --> 00:07:39,199 subscapularis mechanism of injury for rotator cuff. Injury is going to be a few 116 00:07:39,199 --> 00:07:43,399 different things. So degeneration like chronic degenerative tear that's usually going to be seen 117 00:07:43,439 --> 00:07:46,040 in older patients. Impingement. Chronic and pingement can also lead to a tear 118 00:07:46,240 --> 00:07:50,720 and then overload, so like tension overload and athletes are continually throwing like in 119 00:07:50,759 --> 00:07:56,399 baseball or jobs with repetitive overhead movement. In general, the cause of rotator 120 00:07:56,439 --> 00:08:00,920 cuff tears, it's multifactorial degeneration and pingement, over they can all contribute. 121 00:08:00,959 --> 00:08:05,000 There's not really anything I'd say is super important to memorize. The high yield 122 00:08:05,040 --> 00:08:07,240 things for a rotator cuff is going to be the presentation of physical exam tests, 123 00:08:07,639 --> 00:08:13,240 so clinical manifestations. There's two things to know here. Overhead pain and 124 00:08:13,319 --> 00:08:18,399 pain at night. That's the key. So pain exacerbated by overhead activities. 125 00:08:18,600 --> 00:08:20,920 So the vignett they're going to describe the patient that's maybe reaching up to the 126 00:08:20,959 --> 00:08:24,839 shelf and experiencing pain, brushing their hair and having pain things like that, 127 00:08:24,920 --> 00:08:28,839 definitely look out for. The location of the pain is usually going to be 128 00:08:28,839 --> 00:08:31,919 over their lateral deltoid, so the anterior lateral portion of the shoulder. And 129 00:08:31,919 --> 00:08:35,159 then they also may describe pain at night, so complaining like when the patient's 130 00:08:35,240 --> 00:08:39,279 lying on the shoulder at night, they're experiencing pain. That's the classic presentation. 131 00:08:39,320 --> 00:08:43,720 Will look out for in vignettes the pain over their lateral deltoid when they're 132 00:08:43,720 --> 00:08:46,080 reaching overhead, or complaining of pain at night and real life, though it's 133 00:08:46,120 --> 00:08:50,600 possible that they may just develop weakness decreased range of motion. Other studies even 134 00:08:50,600 --> 00:08:54,000 suggest a large portion of rotator cuff tears. They're actually asymptomatic. But for 135 00:08:54,039 --> 00:08:58,759 the exam pain with overact, pain with overhead activities, pain at night done 136 00:09:00,080 --> 00:09:03,720 physical exam. So there's a lot of special maneuvers for the rotator cuff when 137 00:09:03,720 --> 00:09:07,679 you're looking for impingement and tears. So three that I feel you should be 138 00:09:07,679 --> 00:09:11,559 familiar with at seem to be tested on the most is the Hawkins test, 139 00:09:11,639 --> 00:09:13,039 the near tests, and the empty Can test. Again, these are for 140 00:09:13,080 --> 00:09:18,120 both impingement and tears. So let's start with the Hawkin and the Near test. 141 00:09:18,200 --> 00:09:22,440 These are both really good tests to test to assess for impingement. So 142 00:09:22,480 --> 00:09:26,000 the Hawkins test, also known as the Hawkins Kennedy impingement test, the patient's 143 00:09:26,039 --> 00:09:31,759 going to have their shoulders stabilize and positioned in ninety degrees of elevation. The 144 00:09:31,799 --> 00:09:33,840 elbow is going to be bent to ninety degrees. The examiner is going to 145 00:09:33,879 --> 00:09:39,480 place internal force on the patient's shoulder, and then any reproduction of pain elicited 146 00:09:39,480 --> 00:09:43,039 by the internal rotation would be a positive test for impingement. Again, if 147 00:09:43,039 --> 00:09:45,480 you need visuals on any of these, check out the YouTube channel. Have 148 00:09:45,519 --> 00:09:48,320 a lot of different pictures and things like that that kind of help. So 149 00:09:50,360 --> 00:09:52,919 the way that I used to remember this test, the Hawkins test, was 150 00:09:54,159 --> 00:09:56,000 if you can visualize when you were a kid, did you ever call someone 151 00:09:56,000 --> 00:10:01,039 a chicken? You do the little arm flapping thing like wings. That's exactly 152 00:10:01,039 --> 00:10:03,039 what this looks like when you're doing the Hawkins test. Their shoulders up, 153 00:10:03,080 --> 00:10:07,279 their elbows bent. So when I see Hawkins test, it makes me think 154 00:10:07,320 --> 00:10:09,840 of a hawk flapping its wings. And I'll help you remember this is the 155 00:10:09,840 --> 00:10:11,759 one where it looks like you're flapping your wings like a bird or a hawk, 156 00:10:13,000 --> 00:10:16,399 with the elbow bent, shoulder elevator elevated, and the examiner applying internal 157 00:10:16,679 --> 00:10:20,679 rotation. That's exactly what this looks like. You'll have to take my word 158 00:10:20,679 --> 00:10:22,759 for it or check out some pictures of the Hawkins test, but it looks 159 00:10:22,840 --> 00:10:28,080 like somebody like flapping their wings like a hawk. So again remember that in 160 00:10:28,120 --> 00:10:31,759 your os keys and things like that, you'll remember what the Hawkins test looks 161 00:10:31,759 --> 00:10:35,320 like and what it involves. So remember Hawkins tests flapping your wing like a 162 00:10:35,320 --> 00:10:37,080 hawk. I let's talk about the near test. So the near test, 163 00:10:37,200 --> 00:10:43,399 the shoulder is going to be forcibly flexed and internally rotated. So one hand 164 00:10:43,480 --> 00:10:46,279 is going to be placed on the shoulder and the scapular area to keep the 165 00:10:46,279 --> 00:10:50,600 shoulder from shrugging. The other hand is going to passively lift the arm all 166 00:10:50,600 --> 00:10:54,759 the way up to the ear. The arm is going to be internally rotated 167 00:10:54,759 --> 00:10:58,480 with the thumb facing down, and then any reproduction of pain is a positive 168 00:10:58,480 --> 00:11:01,919 test for impingement. May see some variations of this test with the arm and 169 00:11:01,000 --> 00:11:05,120 neutral position rather than internal, but most of the time it's going to have 170 00:11:05,159 --> 00:11:09,120 internal rotation. Ice Remember near is by the ear because and this test, 171 00:11:09,159 --> 00:11:11,879 your arm goes all the way up and the shoulder winds up right next to 172 00:11:11,919 --> 00:11:15,360 the ear. So when you see the near test, remember near is the 173 00:11:15,360 --> 00:11:18,759 one by the ear. And then finally, the empty can test, also 174 00:11:18,840 --> 00:11:22,879 known as the Job's test. This is a good test to evaluate superspinatus function. 175 00:11:22,200 --> 00:11:26,600 Sometimes it's considered the gold standard test due to how well it isolates the 176 00:11:26,679 --> 00:11:30,440 superspinatus in the way that the arm is position to really isolates it well. 177 00:11:30,919 --> 00:11:33,480 So the patient's going to place a straight arm out at about ninety degrees of 178 00:11:33,759 --> 00:11:39,600 ab duction and thirty degrees of forward flection, then internally rotating the arm completely. 179 00:11:39,639 --> 00:11:43,320 The thumb is going to be pointing down. And then the patient then 180 00:11:43,440 --> 00:11:46,039 resists. The clinicians attempts to depress the arm, so you're trying to push 181 00:11:46,080 --> 00:11:50,600 it down. They're resisting. So again the patient raises their arm forward, 182 00:11:50,879 --> 00:11:54,440 elbow extended, thumbs down as if emptying a can. Examiner's going to apply 183 00:11:54,480 --> 00:11:56,320 pressure to the top of the arm, pushing it down. The patient attempts 184 00:11:56,320 --> 00:12:01,000 to resist. This. Pain without weakness is going to suggest tendinopathy. Pain 185 00:12:01,120 --> 00:12:05,080 with weakness is consistent with the tendon tear There's a lot of other tests, 186 00:12:05,080 --> 00:12:07,879 but in my experience, those are the three that seem to be most often 187 00:12:07,960 --> 00:12:13,519 tested on, so definitely be familiar with those three. Now, treatment conservative 188 00:12:13,600 --> 00:12:16,440 versus surgical repair, there's nothing really specific to know here. Treatment is all 189 00:12:16,480 --> 00:12:20,200 going to depend on. It's really a several factors like the duration of the 190 00:12:20,240 --> 00:12:24,320 symptoms, the type of tear partial versus full thickness, patient age, activity 191 00:12:24,399 --> 00:12:28,039 level, etc. That's going to guide the treatment as to whether or not 192 00:12:28,080 --> 00:12:31,519 they're going to need surgical repair or if they're better suited for say physical therapy. 193 00:12:31,960 --> 00:12:35,879 Now, if we're talking about tendonitis and the impingement of the rotator cuff, 194 00:12:35,039 --> 00:12:39,120 treatment is primarily going to be physical therapy and sets, etc. You're 195 00:12:39,159 --> 00:12:43,360 gonna find with most of MSK treatment is pretty repetitive. It's not very high 196 00:12:43,440 --> 00:12:46,200 yield. That's why I kind of run through them quickly because there's just not 197 00:12:46,279 --> 00:12:50,600 much to know from an exam standpoint, So from breezing over and I'm skipping 198 00:12:50,600 --> 00:12:52,799 in some cases, it's just because there's nothing really for you to memorize. 199 00:12:52,799 --> 00:12:56,480 If there's something high yield for treatment, I'll definitely make sure to bring it 200 00:12:56,519 --> 00:12:58,440 to your attention, all right, so let's move on another area of the 201 00:12:58,480 --> 00:13:03,960 shoulder known as adhesive capsulitis, also known as a frozen shoulder. So this 202 00:13:03,039 --> 00:13:09,279 is a painful and stiff glenohumeral joint that has lost its distensibility and range of 203 00:13:09,320 --> 00:13:11,159 motion. So it's exactly what it sounds like. It's a frozen shoulder. 204 00:13:11,159 --> 00:13:13,960 It's hard to move. Passive and active range of motion are going to be 205 00:13:15,000 --> 00:13:18,519 substantially reduced. Risk factors diabetes, this is a big one. Remember that 206 00:13:18,559 --> 00:13:22,480 frozen shoulder is very common in diabetics, and the vignette it will very very 207 00:13:22,480 --> 00:13:26,120 likely be a diabetic patient. There's actually a study that showed the incidence of 208 00:13:26,200 --> 00:13:31,600 frozen shoulder and patients with long standing type one diabetes had a lifetime prevalence of 209 00:13:31,679 --> 00:13:35,039 up to seventy six percent. So diabetic patients remember that the other risk factor 210 00:13:35,080 --> 00:13:39,960 to know is thyroid disorders, particularly hypothyroidism, may increase the risk for frozen 211 00:13:41,000 --> 00:13:43,480 shoulder as much as two point seven times. And then there's some other causes 212 00:13:43,480 --> 00:13:48,360 that you shouldn't memorize should not memorize, like dyslipidemia, prolonged immobilization, stroke, 213 00:13:48,399 --> 00:13:52,440 auto immune disease. Secondary problem after shoulder injury. Focus on diabetes, 214 00:13:52,519 --> 00:13:56,960 they got that sticky shoulder from all that extra sugar and thyroid disorders. And 215 00:13:58,000 --> 00:14:01,440 then also know that this is very common in women, particularly in the fifth 216 00:14:01,480 --> 00:14:05,159 and sixth decades of life. It's actually really rare to see the impatience under 217 00:14:05,200 --> 00:14:09,039 forty. So in the vignette, be looking for a female in their fifties 218 00:14:09,120 --> 00:14:13,320 or sixties with diabetes or thyroid disorder. For diagnosis, There's nothing I really 219 00:14:13,360 --> 00:14:16,519 know here. Frozen shoulder is very much a clinical diagnosis made on the basis 220 00:14:16,559 --> 00:14:22,720 of the medical history. The physical exam imaging really has very little value except 221 00:14:22,720 --> 00:14:26,159 just to rule out your differentials like osteoarthritis and things like that. Treatment is 222 00:14:26,200 --> 00:14:31,519 also pretty low yield most cases. Frozen shoulders is self limited condition. Physical 223 00:14:31,559 --> 00:14:35,480 therapy is the most commonly employed treatment option. Google corticoid injections and SAIDs other 224 00:14:35,519 --> 00:14:39,240 supportive measures, but nothing really to commit to memory here, all right, 225 00:14:39,279 --> 00:14:45,840 So moving on down the arm. Supercondular humorous fractures, so supercondular fractures of 226 00:14:45,879 --> 00:14:50,320 the distal humorous You're going to see this most common in children two to seven 227 00:14:50,399 --> 00:14:54,639 years old, so most frequently in children two to seven years old. So 228 00:14:54,799 --> 00:14:58,360 be looking for a child in the vignette. Supercondular fractures are actually the most 229 00:14:58,399 --> 00:15:03,600 common mediatric elbow fracture as far as the mechanism of injury. Foosh with the 230 00:15:03,639 --> 00:15:09,080 elbow extended. So foosh foosh with the elbow hyper extended. So you're gonna 231 00:15:09,080 --> 00:15:13,720 hear me saying that a lot. So extension fractures are actually going to account 232 00:15:13,720 --> 00:15:18,519 for approximately ninety five percent of all supercondular fractures, and this is typically going 233 00:15:18,519 --> 00:15:22,200 to be from a foosh mechanism. So foosh stands for fall on outstretched hand 234 00:15:22,399 --> 00:15:24,840 and then in this case, the elbow is going to be hyper extended. 235 00:15:26,039 --> 00:15:31,480 Like we talked about before, this is really seen very commonly in children, 236 00:15:31,480 --> 00:15:35,159 and the reason is because children have this increased flexibility in their joints, They 237 00:15:35,159 --> 00:15:39,600 have this ligamentous laxity, and when they fall with their arm extended out, 238 00:15:39,919 --> 00:15:43,600 they're more susceptible to hyper extending the arm when they fall, and then hyper 239 00:15:43,600 --> 00:15:48,600 extension is what generally leads to this type of fracture, to a supercondular fracture. 240 00:15:48,639 --> 00:15:52,600 So remember supercondular foosh with hyper extension diagnosis, you're going to get an 241 00:15:52,639 --> 00:15:56,879 X ray and once you're looking for here is fat pad. So the only 242 00:15:56,960 --> 00:15:58,919 thing I really think you should be aware of, at least for imaging when 243 00:16:00,039 --> 00:16:03,840 comes to supercondular fractures for the exam are fat pads. So in a non 244 00:16:03,919 --> 00:16:08,200 displaced or minimally displaced fracture of this region, sometimes you actually can't see the 245 00:16:08,200 --> 00:16:11,919 fracture. Sometimes it can't be visualized. And the only indication that a fracture 246 00:16:12,000 --> 00:16:17,799 is present is an elbow effusion like seen in an anterior sale or posterior fat 247 00:16:17,840 --> 00:16:21,360 pads signs. So let's talk about fat pads for a second. In the 248 00:16:21,399 --> 00:16:23,279 elbow, you have fat pads. Usually they're not visible on X ray. 249 00:16:23,519 --> 00:16:26,559 I'm going to talk about this a little bit more when we get to radio 250 00:16:26,600 --> 00:16:30,200 head fractures. Next your interior verus posterior which you can be normal, which 251 00:16:30,200 --> 00:16:36,159 you cannot. But generally fat pads, particularly posterior fat pads, they're not 252 00:16:36,279 --> 00:16:40,320 visible unless you have an acute injury and then this blood starts to collect. 253 00:16:40,559 --> 00:16:44,840 This hemarthrosis elevates the fat pads out of the coronoid and the electronoid electro non 254 00:16:44,879 --> 00:16:48,919 fossa, and that's what makes them visible on radiographs and actually in more than 255 00:16:48,039 --> 00:16:52,919 ninety percent of cases where imaging shows posterior fat pad displacement, a fracture is 256 00:16:52,919 --> 00:16:56,720 seen on initial or follow up radiographs. So at the elbow will be looking 257 00:16:56,720 --> 00:17:02,519 for your fat pads and then also be aware there is something called an interior 258 00:17:02,679 --> 00:17:06,799 humeral line. If there's any displacement of this line, this can also indicate 259 00:17:06,799 --> 00:17:08,519 a displaced fracture. I don't think they're going to ask you about this though, 260 00:17:08,680 --> 00:17:12,559 Just really focus on your fat pads now. Complications. There's a lot 261 00:17:12,559 --> 00:17:18,680 of complications that can arise from a supercondular fracture, vascular insufficiency, nerve injury, 262 00:17:18,720 --> 00:17:22,240 compartment syndrome, So I want to make sure you're doing a complete neurovascular 263 00:17:22,240 --> 00:17:25,079 evail in these patients. You need to check the sensory and the motor function 264 00:17:25,359 --> 00:17:27,400 of the medial, of the median, radio owner nerves. You want to 265 00:17:27,400 --> 00:17:30,839 assess the radio and brakual pulses. What you really need to be looking out 266 00:17:30,839 --> 00:17:34,799 for. An exam question when it comes to complications of a supercondular fracture is 267 00:17:34,839 --> 00:17:41,920 something called Volkman's schemic contracture. So this isn't common, but it's definitely tested 268 00:17:41,920 --> 00:17:44,440 on. So when you have this type of fracture and you have a vascular 269 00:17:44,480 --> 00:17:48,680 injury and swelling. This can potentially lead to compartment syndrome, and if that 270 00:17:48,759 --> 00:17:52,319 compartment syndrome isn't treated in a timely manner, the associated a schemia and infraction 271 00:17:52,359 --> 00:17:56,920 can lead to Volkman's a schemic contraction. So what this causes is you have 272 00:17:57,000 --> 00:18:02,240 this fixed flection of the elbow, the extension of the MCP joints. But 273 00:18:02,359 --> 00:18:06,160 it really simply it's this claw like deformity of the hands fingers and the risk 274 00:18:06,640 --> 00:18:10,440 risk. So for the exam, if you see Volkman's contracture right away, 275 00:18:10,480 --> 00:18:14,039 be thinking of a supercondular fracture, because while this can be seen with other 276 00:18:14,039 --> 00:18:18,000 types of injuries of the arm, it's most commonly seen with supercondular fractures. 277 00:18:18,000 --> 00:18:23,160 So associate those two in your head Volkman's supercondular, supercondular Volkman's or just remember 278 00:18:23,200 --> 00:18:27,680 what I did and remember my vocal at my Volkswagens in super condition, so 279 00:18:27,839 --> 00:18:37,480 Volkswagen helps remember Volksman contracture. Supercondition helps remember supercondular fracture. So my Volkswagen's 280 00:18:37,519 --> 00:18:45,799 in supercondition Volkswagen Volkman's contracture supercondition helps you remember supercondular fracture. All right, 281 00:18:45,880 --> 00:18:51,359 so treatment is going to be splint verse surgical most displaced or minimally displaced fractures, 282 00:18:51,359 --> 00:18:55,319 you're going to apply a posterior your splint and sling. Displaced fractures generally 283 00:18:55,519 --> 00:19:00,119 be repaired surgically closed versus open reduction with percutaneous pin play. Nothing really to 284 00:19:00,160 --> 00:19:04,440 memorize here. So for supercondular fractures, remember this is very likely going to 285 00:19:04,440 --> 00:19:07,880 be a young child in the vignette. It's going to be a foosh injury 286 00:19:07,880 --> 00:19:11,759 with hyper extension. You remember fall on outstretched hand, Look for your fat 287 00:19:11,799 --> 00:19:17,279 pads on X ray, and then finally remember your Volksman's contracture for potential complications. 288 00:19:17,279 --> 00:19:22,359 Remember by Volkswagens in supercondition. Okay, so next radiohead fractures. There's 289 00:19:22,359 --> 00:19:25,319 really just a few things to know here. The mechanism of injury is going 290 00:19:25,359 --> 00:19:29,960 to be another foosh, So another foushure like in supercondular humeral fractures and many 291 00:19:29,960 --> 00:19:33,640 other fractures of the arm. Really, so falling onto an outstretched hand is 292 00:19:33,680 --> 00:19:37,200 the most common mechanism for radiohead or neck fractures. Because this type of injury 293 00:19:37,480 --> 00:19:44,079 there's this sudden impaction on the radius and onto the capitulum. So as far 294 00:19:44,079 --> 00:19:45,559 as diagnosis, you're going to get your X ray. You're looking for fat 295 00:19:45,559 --> 00:19:49,519 pads here again. Now, the fat pads in radiohead fractures are even more 296 00:19:49,559 --> 00:19:56,039 important than supercondular fractures that we just discussed before, because non displaced radiohead fractures 297 00:19:56,039 --> 00:20:00,880 can very very often be missed and an elevated interior and posterior fat pads maybe 298 00:20:00,960 --> 00:20:07,160 the only sign of an occult radiohead fracture. So be looking for those fat 299 00:20:07,200 --> 00:20:08,720 pads in the vignette and in real life. Wanted to give you a little 300 00:20:08,720 --> 00:20:12,680 bit of extra knowledge while we're on the topic of fat pads, so I 301 00:20:12,680 --> 00:20:18,039 interior fat pads can actually be a normal variant, particularly in children. While 302 00:20:18,039 --> 00:20:23,119 a posterior fat pad should really never be visible. It'll almost always indicate trauma. 303 00:20:23,240 --> 00:20:26,519 So again, remember anterior fat pads can sometimes be a normal finding, 304 00:20:26,720 --> 00:20:32,200 while posterior will almost always indicate a fusion caused by trauma. And I used 305 00:20:32,200 --> 00:20:36,119 to remember and tieror fat pads and tior with an A can be AOKA, 306 00:20:36,640 --> 00:20:41,720 and posterior fat pads with a P are always problematic. So anterior AOKA posterior 307 00:20:41,720 --> 00:20:45,240 problematic helps you remember which one can be normal, which one is always bad. 308 00:20:45,559 --> 00:20:48,359 Treatment is going to be splint for a surgical nothing really to know here. 309 00:20:48,480 --> 00:20:51,920 Depending on the severity of the fracture and mobilization with a sling or posterior 310 00:20:51,960 --> 00:20:56,119 splint may be sufficient for surgical repair for your displaced For more severe fractures, 311 00:20:56,440 --> 00:21:00,640 again, little mill for radiohead fractures, just remember your food injury. You 312 00:21:00,720 --> 00:21:04,039 know your fat pad sign for those occult fractures. Occult fractures. If I 313 00:21:04,039 --> 00:21:07,440 didn't mention this before, it just means a hidden fracture that's not visible on 314 00:21:07,519 --> 00:21:12,759 imaging. Let's move on to ulner shaft or night stick fractures. Really, 315 00:21:12,880 --> 00:21:15,559 very little to know for this one. I only bring it up for some 316 00:21:15,599 --> 00:21:18,599 reason. This does come up on exams. Main takeaway here is to know 317 00:21:18,640 --> 00:21:22,039 the type of injury that's related to the specific fracture. So this is going 318 00:21:22,079 --> 00:21:26,400 to be an isolated ulner shaft fracture. The mechanism of injury is going to 319 00:21:26,440 --> 00:21:30,319 be a direct blow to the forearm. So these types of fractures almost always 320 00:21:30,400 --> 00:21:33,559 result from a direct blow to the forum. So this happens when the patient 321 00:21:33,640 --> 00:21:37,079 was using the forum to protect their head from their torso, like from a 322 00:21:37,119 --> 00:21:41,079 blow with a night stick or a pool stick or something like that. So 323 00:21:41,119 --> 00:21:44,319 if you're familiar with the mechanism of injury, when you see it in a 324 00:21:44,400 --> 00:21:47,599 vignette, you'll know you'll be looking for an ulner fracture. In the answers, 325 00:21:47,920 --> 00:21:52,079 treatment is going to be non operative treatment verse surgical repair. So casting 326 00:21:52,160 --> 00:21:56,160 splinting is the accepted approach for uncomplicated night sticks fractures. But if the fracture 327 00:21:56,200 --> 00:22:02,599 is comminuted over fifty percent displacement, these types of fractures are suited for better 328 00:22:02,599 --> 00:22:07,440 suited for surgical repair. Okay, Montezia and Galiazzi fractures. So with Montezia 329 00:22:07,480 --> 00:22:11,279 and Galiazzi fracture is the only thing I feel you really need to remember that's 330 00:22:11,319 --> 00:22:15,759 normally tested on is what bonus fracture and dislocated in each. The rest of 331 00:22:15,799 --> 00:22:21,359 the stuff's pretty low yield that you need to know. So Montezia is going 332 00:22:21,400 --> 00:22:26,119 to be a proximal ulnar fracture accompanied by a radial head dislocation. So again 333 00:22:26,160 --> 00:22:33,480 Montesia proximal ulnar fracture companied by a radial head dislocation. Galiazzi is going to 334 00:22:33,480 --> 00:22:38,039 be a radial midshaft fracture associated with a dislocation of the distal radial ulnar joint. 335 00:22:38,559 --> 00:22:42,160 So both of these are not just fractures, but they're also dislocations, 336 00:22:42,319 --> 00:22:47,440 and you need both to meet the criteria for either a Montezia or a Galiazzi 337 00:22:47,480 --> 00:22:49,920 fracture, you need to have both a fracture and the dislocation. Diagnosis is 338 00:22:49,960 --> 00:22:52,759 going to be done with an X ray. Treatment is going to be surgical 339 00:22:52,799 --> 00:22:56,640 repair. Generally, in both of Montezia and a Galiazzi fracture, treatment is 340 00:22:56,680 --> 00:23:02,880 almost always going to be surgical. Montega fractures in particularly are almost in particular, 341 00:23:02,920 --> 00:23:07,039 almost always unstable and always require surgical treatment. Most of the time this 342 00:23:07,119 --> 00:23:11,079 is going to be with an RIF open reduction internal fixation. So again the 343 00:23:11,160 --> 00:23:15,279 highest yield thing is remembering which fracture and dislocation is of what bone in each 344 00:23:15,279 --> 00:23:19,319 condition. So the way that you remember that is by remembering gruesome murder. 345 00:23:19,640 --> 00:23:25,960 So gruesome murder helps to remember which bonus fracture and then secondly which is dislocated, 346 00:23:26,000 --> 00:23:30,839 So remember gruesome murder. So for Montigia and Galiazzi fracture, so gruesome 347 00:23:30,079 --> 00:23:36,200 The first three letters in gruesome are gru, so the G stands for Galiazzi, 348 00:23:36,319 --> 00:23:40,119 the R stands for radius fracture, and then the U stands for owner 349 00:23:40,200 --> 00:23:45,200 dislocation. So that's in gruesome Galiazzi our radius fracture, and then the U 350 00:23:45,279 --> 00:23:48,000 stands for owlnar dislocation. I know, technically I said this is a dislocation 351 00:23:48,079 --> 00:23:52,200 or instability of the radio owner joint, not specifically in older dislocation, but 352 00:23:52,279 --> 00:23:56,240 in most cases, what we actually see is this dorsally displaced owner head, 353 00:23:56,440 --> 00:24:00,240 which will be very evident on X ray, so you'll see the owner hopped 354 00:24:00,240 --> 00:24:03,839 out of place. So remember gruesome gru Galiazzi, radius fracture, owner dislocation, 355 00:24:04,359 --> 00:24:07,279 and then murder the second part of the sentence. The first three letters 356 00:24:07,279 --> 00:24:11,720 are Mu, R, and that stands for M stands for Montezia, U 357 00:24:11,880 --> 00:24:15,119 stands for ulnar fracture, and then the R stands for radial head dislocation. 358 00:24:15,160 --> 00:24:19,599 So again remember gruesome murder. First three letters of gruesome, Galiazzi, radius 359 00:24:19,640 --> 00:24:23,599 fracture, owner dislocation, first three letters of murder. Help you remember Montezia, 360 00:24:23,920 --> 00:24:29,480 ulner fracture and radio head dislocation. Okay, radial head subluxation This is 361 00:24:29,480 --> 00:24:33,119 also known as a nursemaide elbow. It's important to know this because not only 362 00:24:33,160 --> 00:24:36,960 may it come up on an exam, but if you wind up working anywhere 363 00:24:36,960 --> 00:24:40,279 with pediatric patients, you're going to see this very frequently. So what happens 364 00:24:40,279 --> 00:24:44,640 here you have the movement of the head of the radius that slips under the 365 00:24:44,680 --> 00:24:48,480 annular ligament. So we talked about this before, but the ligaments and children 366 00:24:48,480 --> 00:24:51,599 are much more lax and weak. So in a child, when you have 367 00:24:51,680 --> 00:24:55,200 this sudden pulling on the arm, pulling on the distill radius, the annular 368 00:24:55,240 --> 00:24:57,519 ligament, which is a band of fibers that encircles the head of the radius, 369 00:24:57,759 --> 00:25:00,799 it slips right over the head the radius, and then this slides into 370 00:25:00,839 --> 00:25:04,920 the radio humeral joint where it becomes trapped and these children start to have pain. 371 00:25:06,559 --> 00:25:10,880 It's most common in one to four years of age, so common between 372 00:25:10,920 --> 00:25:14,559 the ages of one to four years. Eighty percent of cases are actually going 373 00:25:14,599 --> 00:25:17,720 to fall within the one to three year range. So if it's not a 374 00:25:17,720 --> 00:25:19,400 young child in the vignette, it's not a nursemaid elbow. This is a 375 00:25:19,480 --> 00:25:22,799 one hundred percent going to be a young child. The reason we see this 376 00:25:23,000 --> 00:25:27,319 more frequently in young children not adults. Is because the attachment of the annular 377 00:25:27,440 --> 00:25:32,079 ligament is much weaker and children than adults. As the child grows, the 378 00:25:32,079 --> 00:25:36,079 attachment between the annular ligament and the radius becomes thicker and stronger, and it 379 00:25:36,079 --> 00:25:40,039 prevents the subluxcation. Usually by the age of five years, the ligament is 380 00:25:40,039 --> 00:25:42,359 going to be strong enough and thick enough that it's highly unlikely to tear to 381 00:25:42,400 --> 00:25:45,519 become displaced. So generally you're looking for a child one to four years. 382 00:25:45,720 --> 00:25:48,680 I'm not saying it's impossible to see this like in a seven or eight year 383 00:25:48,680 --> 00:25:52,000 old, but probably not very common at all. Look for a very young 384 00:25:52,079 --> 00:25:56,480 child. In the vignette mechanism of injury, this is going to be a 385 00:25:56,519 --> 00:26:02,759 polling injury. So the classic mechanism for a radiohead subluxation is going to be 386 00:26:02,960 --> 00:26:06,000 consisting of a pull injury. So, for instance, a parent grabs the 387 00:26:06,079 --> 00:26:08,920 arm of the child to prevent them from falling, maybe the child's being swung 388 00:26:08,960 --> 00:26:12,400 by the forearms or during play with their siblings or parents. You're looking for 389 00:26:12,480 --> 00:26:15,400 some type of pull or tug on the arm. And even yet, the 390 00:26:15,440 --> 00:26:18,640 reason why this is actually called a nursemaid elbow was because back in the day, 391 00:26:19,839 --> 00:26:23,200 when nursemaids as they were called back in the day, took care of 392 00:26:23,279 --> 00:26:26,960 children, they were often blamed for causing this injury by tugging on the child's 393 00:26:27,000 --> 00:26:30,519 arm. So look for that pulling or tugging of the arm. Diagnosis is 394 00:26:30,559 --> 00:26:33,440 going to be clinical. So a majority of the time this is a clinical 395 00:26:33,480 --> 00:26:37,200 diagnosis. They had a pulling or tugging type injury. They fit the age 396 00:26:37,279 --> 00:26:41,000 range on physical exam, they don't have any bony tenderness, no deformity, 397 00:26:41,000 --> 00:26:45,640 no swelling. Usually that's all you need to make the diagnosis. Imaging is 398 00:26:45,720 --> 00:26:51,039 usually not necessary. Now treatment there's very few things in medicine where we can 399 00:26:51,039 --> 00:26:53,759 fix someone's problems and a matter of seconds and make them feel completely back to 400 00:26:53,839 --> 00:26:59,079 normal. But this is one of those few circumstances. So with treatment it's 401 00:26:59,079 --> 00:27:02,079 going to be a close reduction, and there's a couple of ways to do 402 00:27:02,160 --> 00:27:04,559 this. The technique preferred by up to date, which has a higher rate 403 00:27:04,559 --> 00:27:10,880 of success, is reduction with hyperpronation rather than the other alternative, which is 404 00:27:10,920 --> 00:27:17,000 this supernation flection method. So the way you do the hyperpronation method is going 405 00:27:17,039 --> 00:27:19,400 to be you hold the child's arm at the elbow. You place pressure with 406 00:27:19,440 --> 00:27:23,319 a finger on the radio head and then the other hand holds the discal forum 407 00:27:23,359 --> 00:27:26,400 and you hyper pronate the forum, so you turn the arm all the way 408 00:27:26,440 --> 00:27:30,240 over and in a lot of times you're going to feel this click or this 409 00:27:30,319 --> 00:27:33,000 pop over the radial head. But it reduces and then these kids within minutes 410 00:27:33,000 --> 00:27:36,559 are going to be back to normal and playing and smiling in most cases, 411 00:27:36,599 --> 00:27:41,119 at least from my experience. So for radial head subluxation, main takeaways here 412 00:27:41,359 --> 00:27:45,200 looking for a child under five looking for a pulling injury. It's a clinical 413 00:27:45,200 --> 00:27:48,880 diagnosis and treatment is going to be with a closed reduction, very straightforward. 414 00:27:48,039 --> 00:27:52,799 All right, Medio versus lateral epicond litis. These are really simple, there's 415 00:27:52,880 --> 00:27:55,839 very little to know. But the reiblement is you can easily get them mixed 416 00:27:55,920 --> 00:27:59,000 up and miss out on an easy exam question. So let's go over what 417 00:27:59,039 --> 00:28:02,279 you need to know the little differences between the two and in the monic to 418 00:28:02,319 --> 00:28:07,000 remember them. So, lateral epicondolitus, which is also known as tennis elbow, 419 00:28:07,680 --> 00:28:11,079 it's a frequent complaint of tennis players, actually up to fifty percent of 420 00:28:11,119 --> 00:28:15,119 tennis players. It's mostly due to poor technique. So it's an overuse injury 421 00:28:15,160 --> 00:28:21,799 of the origin of the common extensor tendon which leads to tendinosis and inflammation of 422 00:28:21,839 --> 00:28:27,880 the extensor carpi radialis brevis precipitated by repetitive wrist extension. And the reason why 423 00:28:27,880 --> 00:28:33,319 you have painted the lateral epicondyle is because the lateral epicondo of the elbow is 424 00:28:33,359 --> 00:28:37,039 the bony origin for the wrist extensors. So who are you looking out for? 425 00:28:37,160 --> 00:28:40,359 This is going to be of course tennis players. Like I said before, 426 00:28:40,599 --> 00:28:44,440 tennis is the most common sport to cause lateral epicondolitus. It can be 427 00:28:44,440 --> 00:28:48,079 seen in other sports squash, badminton, as well as certain occupations like carpenters, 428 00:28:48,079 --> 00:28:51,880 bricklayers, seamstresses. But for the sake of the exam, be looking 429 00:28:51,880 --> 00:28:56,279 for your tennis player, and on exam you're going to be looking for localized 430 00:28:56,319 --> 00:29:03,240 tenderness over the lateral epicondyle and pain with resisted wrist extension. So lateral epicondo 431 00:29:03,319 --> 00:29:10,400 lightis associated with extensive extension and extensor so pain with risk extension. On physical 432 00:29:10,400 --> 00:29:17,160 exam, overuse of the extensor tendon, the extensor carpi radialist brevis precipitated from 433 00:29:17,160 --> 00:29:21,920 repetitive risk extension. Remember what I keep saying, extension extensor, lateral epikind 434 00:29:21,920 --> 00:29:26,039 of lightis. Remember extension extension extension That's how they're going to get you on 435 00:29:26,119 --> 00:29:27,720 an exam question if you don't remember this and you get it mixed up with 436 00:29:27,839 --> 00:29:33,240 medial epicind of lightis, which is the opposite involving flexion rather than extension treatment. 437 00:29:33,440 --> 00:29:37,960 It's going to be conservative and SAIDs activity modification, steroid injections, counter 438 00:29:38,039 --> 00:29:42,359 force braces, not anything really important to know here. Medial epicondo lightis. 439 00:29:42,440 --> 00:29:48,000 So this is also known as golfer's elbow. It is an overuse injury involving 440 00:29:48,039 --> 00:29:53,839 the proximal tenders of the pronator, terrace and flex or carpi. Radialists probably 441 00:29:53,880 --> 00:29:59,559 mispronouncing all of these overt imachin I am. It's primarily due to repetitive forceful 442 00:30:00,160 --> 00:30:03,880 forearm pronation and risk flection. So this is the opposite and lateral we were 443 00:30:03,880 --> 00:30:08,519 talking all about extension extens or tendence down medial It's all about the flection flex 444 00:30:08,599 --> 00:30:14,559 or carpon radialis caused by repetitive risk flection and just like we talked about before 445 00:30:14,799 --> 00:30:18,079 in lateral epicondolitis, the reason why you have pain in the medial epicondo in 446 00:30:18,119 --> 00:30:23,519 this case is because the medial epicondyle is the common origin of the forearm flexor 447 00:30:23,599 --> 00:30:27,759 and and the pronator muscles. So in the vignette you're probably going to get 448 00:30:27,759 --> 00:30:33,839 a golfer medial epicondolitis, as we know is called golfer's elbow. But interestingly 449 00:30:34,000 --> 00:30:38,359 enough, around ninety percent of cases are actually non sports related, in particular 450 00:30:38,759 --> 00:30:45,359 occupational settings with repeated forceful gripping during heavy labor like plumbers, carpenters, construction 451 00:30:45,359 --> 00:30:48,880 workers. But for the exam, I probably remember and focus on your golfers 452 00:30:48,559 --> 00:30:53,240 on physical exam. They're going to have localized tenderness over the medial epicondyle and 453 00:30:53,359 --> 00:30:59,759 pain with resisted wrist flection, so flection flection, flection treatment is going to 454 00:30:59,799 --> 00:31:03,680 be the same as in lateral conservative and SAIDs activity modifications, steroid injections, 455 00:31:03,720 --> 00:31:07,359 counterforce braces. Nothing to memorize there, all right, So the main thing 456 00:31:07,640 --> 00:31:14,279 to remember for both later epicondolitis remember tennis players pain with wrist extension against resistance 457 00:31:14,599 --> 00:31:21,359 problem with the extensor tendence caused by repetitive risk extension, Lateral should equal extension 458 00:31:21,480 --> 00:31:26,160 in your mind. Now, medial epicondolitis golfers pain with risk flection against resistance 459 00:31:26,440 --> 00:31:30,759 problem with the flex or muscles caused by repetitive wrist flection. Medial should equal 460 00:31:32,119 --> 00:31:34,720 flection in your mind. If you can remember one by method of exclusion, 461 00:31:34,759 --> 00:31:37,799 you can remember the other. And here's how you're going to do that. 462 00:31:37,039 --> 00:31:41,960 So with medial epicondolitis aka golfer's elbow, I want you to remember mini golf 463 00:31:42,079 --> 00:31:47,759 is fun. The M and mini helps you remember this is medial epicondel involved 464 00:31:48,000 --> 00:31:52,240 in golfer's elbow golf obviously because this is also known as golfer's elbow. And 465 00:31:52,319 --> 00:31:56,440 then the F and fun helps you remember this involves flexion, whether it's pain 466 00:31:56,480 --> 00:32:00,839 with risk, flection against resistance on exam or the fact that the flex or 467 00:32:00,920 --> 00:32:05,759 carpyrradialis or that it's caused from repetitive flection. Mini golf is fun. Mini 468 00:32:06,000 --> 00:32:08,240 stands for media up a condal golfer golfer's elbow, and F and fun for 469 00:32:08,279 --> 00:32:13,599 reflection flexor. And then you know ladder up condolitis is the opposite problems with 470 00:32:13,720 --> 00:32:16,160 extension not flection. So remember mini golf is fun on your exam. When 471 00:32:16,160 --> 00:32:20,079 you get a question on one of these, because you're very you very likely 472 00:32:20,119 --> 00:32:22,480 will. And honestly, I had so much trouble remembering which was which until 473 00:32:22,519 --> 00:32:25,359 I came up with anemonic, and now I never forget. So remember mini 474 00:32:25,440 --> 00:32:29,680 golf is fun. Okay. Next, I wanted to talk about two conditions 475 00:32:29,720 --> 00:32:32,119 that are also really easy to get mixed up on an exam, and they 476 00:32:32,119 --> 00:32:37,720 can have similar presentations, and then I'll teach you some ways to help differentiate. 477 00:32:37,960 --> 00:32:39,880 So that's going to be cubital tunnel syndrome and carpal tunnel syndrome. So 478 00:32:39,960 --> 00:32:45,960 let's start with cubital tunnel syndrome, which is ulnar neuropathy. It's a compressive 479 00:32:45,000 --> 00:32:51,640 neuropathy of the ulnar nerve caused by compression in the medial elbow. Clinical manifestations, 480 00:32:51,680 --> 00:32:54,279 this is the highest yield thing to know right here. So paristhesia of 481 00:32:54,319 --> 00:33:00,200 the fifth finger and half of the fourth so numbness tingling in the older nerve 482 00:33:00,240 --> 00:33:02,960 distribution. That's going to be your most common initial complaints. So paristesia is 483 00:33:04,119 --> 00:33:07,240 the small finger and older half of the ring finger. It's also possible to 484 00:33:07,279 --> 00:33:10,920 have radiating pain down from the elbow. Usually you're looking for paristesis and the 485 00:33:10,920 --> 00:33:15,160 little finger and half of the ring finger. That's the key to remember here. 486 00:33:15,799 --> 00:33:17,640 So you're going to get a question, the patient's gonna have some tingling 487 00:33:17,640 --> 00:33:21,880 in their hand. The answer choices, they're going to have both cubital tunnel 488 00:33:21,880 --> 00:33:25,119 syndrome and carpal tunnel. You need to remember which has which nerve distribution, 489 00:33:25,160 --> 00:33:29,200 and this is the way that you remember it. So cubital tunnel starts at 490 00:33:29,200 --> 00:33:31,440 the little finger, the pinky and half of the ring finger. Carpal tunnel 491 00:33:31,519 --> 00:33:35,400 starts at the big finger, the opposite end the thumb or the first digit, 492 00:33:35,759 --> 00:33:37,200 all the way through the other half of the ring finger. So how 493 00:33:37,240 --> 00:33:40,640 do you remember that for the exam, Well, cubital starts with the letters 494 00:33:40,799 --> 00:33:46,720 sub sub cub and as we know, cubs are little bears, bear cubs. 495 00:33:46,839 --> 00:33:51,440 And then help to remember that cubital cub is the one that starts at 496 00:33:51,480 --> 00:33:53,759 the little finger, the pinky, and by method of exclusion, you crewmember, 497 00:33:53,799 --> 00:33:58,079 carpal tunnel started at the other end, the big finger, the thumb. 498 00:33:58,240 --> 00:34:00,079 So as soon as you see cubital tunnels syndrome. Think of a cub, 499 00:34:00,200 --> 00:34:04,160 cub a little bear. Remember this is the one that starts at the 500 00:34:04,200 --> 00:34:07,640 little finger. Carpal tunnel starts at the other hand, at the big finger, 501 00:34:07,720 --> 00:34:09,320 the thumb. So I remember for the exam, and I got the 502 00:34:09,360 --> 00:34:14,079 question right because I remember cubs or little animals. Cubical tunnel syndrome starts at 503 00:34:14,079 --> 00:34:17,800 the little finger. So on physical exam, there's a few different provocation tests 504 00:34:17,800 --> 00:34:22,400 for cubital tunnel, but the one physical test I'd remember for this is the 505 00:34:22,440 --> 00:34:24,280 Tannell sign, as this is the one you'll hear most often, or the 506 00:34:24,320 --> 00:34:30,119 Tennel test. So this is just percussion or tapping over the ular nerve and 507 00:34:30,159 --> 00:34:34,199 the umlar groove of the elbow at the cubital tunnel. So when you do 508 00:34:34,239 --> 00:34:37,119 this, if they have parastesia and the fourth and the fifth finger, that's 509 00:34:37,119 --> 00:34:40,480 a positive Tennell sign. There's also a Tannel sign or test and carpal tunnel 510 00:34:40,519 --> 00:34:43,760 as well, so don't get them mixed up. We'll go over that. 511 00:34:43,880 --> 00:34:47,719 Next treatment for cubital tunnel is going to be conservative for a surgical Initially, 512 00:34:47,840 --> 00:34:53,400 start with activity modification. If this is from some sort of repetitive trauma or 513 00:34:53,400 --> 00:34:58,960 occupational cause. You can use splints and SAIDs. Surgery is really only going 514 00:34:58,960 --> 00:35:02,199 to be for severe or progressive symptoms. Now let's talk about carpal tunnel syndrome. 515 00:35:02,280 --> 00:35:06,679 So this is compression of the media nerve as it travels through the carpal 516 00:35:06,679 --> 00:35:10,400 tunnel. So cubital tunnel syndrome was ulder nerve compression. Carpal tunnel is media 517 00:35:10,480 --> 00:35:15,880 nerve compression. Different nerves affected, different nerve distribution, and different area affected. 518 00:35:15,719 --> 00:35:19,880 So again this is the really important thing you need to remember to differentiate 519 00:35:19,880 --> 00:35:22,519 the two. So in carpal tunnel syndrome, you're going to have pain and 520 00:35:22,599 --> 00:35:25,440 parasthesia of the first three digits and half of the fourth. So a lot 521 00:35:25,480 --> 00:35:28,840 of times the pain is going to be present at night. It's going to 522 00:35:28,920 --> 00:35:32,559 wake them from sleep, the hallmark presentation paint or parasthesia, and the distribution 523 00:35:32,840 --> 00:35:37,119 that includes the media nerve territory, so thumb, the first digit all the 524 00:35:37,159 --> 00:35:40,719 way through the fourth digit, the radial or lateral half, so first, 525 00:35:40,719 --> 00:35:45,079 second, and third and half of the fourth fingers different than cubital tunnel, 526 00:35:45,079 --> 00:35:46,760 which we know started at the opposite end of the hand at the little finger, 527 00:35:47,039 --> 00:35:50,840 fifth digit and half of the other half of the fourth digit on the 528 00:35:50,880 --> 00:35:53,280 ulner side, so carpal tunnel fingers one, two, three and a half 529 00:35:53,280 --> 00:35:58,280 of four, cubital tunnel finger five and half of four. Other things to 530 00:35:58,360 --> 00:36:00,800 look out for, although not as important. They may have weakness or clumsiness 531 00:36:00,800 --> 00:36:05,480 when using their hands. They may have difficulty holding objects, turning keys or 532 00:36:05,519 --> 00:36:08,599 door knobs, buttoning clothing. They may have atrophy of the theen or eminence 533 00:36:08,599 --> 00:36:12,199 in advanced cases. So those are just some other things to be aware of 534 00:36:12,639 --> 00:36:16,360 now. Risk factors. There's a lot of risk factors for carpal tunnel obviously 535 00:36:17,000 --> 00:36:22,039 repetitive hand and risk use, particularly with some occupations authritis, obesity, female 536 00:36:22,079 --> 00:36:27,360 gender, but the ones that I would focus on for the exam are pregnancy. 537 00:36:28,000 --> 00:36:30,119 Third trimester is usually where the symptoms will start to manifest. It can 538 00:36:30,159 --> 00:36:35,360 be diagnosed earlier on than this though diabetes molitis. Both type one and type 539 00:36:35,360 --> 00:36:39,800 two diabetes can be associated with carpal tunnel syndrome and then hypothyroidism. So hypothyroidism 540 00:36:39,880 --> 00:36:45,679 contributes to the development of carpal tunnel by increasing peripheral tissue aedema. So those 541 00:36:45,679 --> 00:36:47,840 are usually the ones you're going to get tested on. Let's talk about one 542 00:36:47,920 --> 00:36:52,360 other high yield area for carpal tunnel that you'll definitely need to know for your 543 00:36:52,360 --> 00:36:57,280 OSCIS. That's your physical exam tests. So there's a few revocative maneuvers you'll 544 00:36:57,320 --> 00:36:59,840 hear about for carpal tunnel. The two that you need to know, the 545 00:36:59,840 --> 00:37:02,519 one that frequently come up are the Tannelle test and the Phalin test. So 546 00:37:02,599 --> 00:37:06,800 Tannell test just like in cubital tunnel, or we tapped on the cubital tunnel, 547 00:37:07,159 --> 00:37:09,840 now we're tapping or percussing over the carpal tunnel. It's easy to get 548 00:37:09,840 --> 00:37:13,639 these physical exam tests mix up. So I used to remember the t and 549 00:37:13,639 --> 00:37:16,519 Tannell stood for tapping because it helps you remember the test is performed. So 550 00:37:16,559 --> 00:37:21,519 you're tapping, tapping, tapping on the median nerve over the carpal tunnel. 551 00:37:21,639 --> 00:37:25,480 Positive test is defined as pain or parasthesia of the median innervated fingers, remember 552 00:37:25,559 --> 00:37:29,320 first finger through half of the fourth and then we have the Phalin test. 553 00:37:29,400 --> 00:37:32,239 So the Phalin test is performed by having the patients bring the dorsal surfaces so 554 00:37:32,360 --> 00:37:37,360 the back of the hands against each other, pushing them up against each other 555 00:37:37,360 --> 00:37:40,440 at the top of the hands push them together and this provides hyperflection of the 556 00:37:40,480 --> 00:37:44,480 risks while the elbows are going to remain flexed. You do this for one 557 00:37:44,519 --> 00:37:47,639 minute straight and a positive test is going to be pain or parastesia again and 558 00:37:47,719 --> 00:37:52,519 the media innervated fingers. The way that I used to remember this is if 559 00:37:52,519 --> 00:37:54,000 you actually look at a picture of the phalin test. When you flop your 560 00:37:54,000 --> 00:37:58,039 hands down like this, it looks like your hands have just kind of like 561 00:37:58,159 --> 00:38:00,639 flopped over. They've fallen over. So when I see phalin tests, I 562 00:38:00,679 --> 00:38:06,119 just remember that your hands have phalin over. Because the hands are flopped over, 563 00:38:06,159 --> 00:38:09,199 they look like they've fallen or phalin over. So I just remember phalin. 564 00:38:09,320 --> 00:38:15,440 Your hands have phalin or fallen over. Tannell. Remember t for tannel 565 00:38:15,519 --> 00:38:20,159 and tapping tapping on the media nerve phalin. Hands have phalin over pressed up 566 00:38:20,159 --> 00:38:22,480 against each other for a minute. So those are the two provocation tests i'd 567 00:38:22,480 --> 00:38:27,400 know for a carpal tunnel. Also be aware there are nerve conduction studies, 568 00:38:27,400 --> 00:38:30,840 electromiography. Those are some other diagnostic tests can help you with the diagnosis, 569 00:38:30,079 --> 00:38:34,079 but focus on those physical exam tests. I talk about the tannel and the 570 00:38:34,079 --> 00:38:38,880 phalin treatment. Conservative or surgical so splinting glucocorticoids, whether it's PO or VA 571 00:38:38,880 --> 00:38:43,039 injections are going to be useful for symptom relief, and up to two thirds 572 00:38:43,039 --> 00:38:46,159 of patients with mild or monitor carpal tunnel severe refractory cases, of course, 573 00:38:46,199 --> 00:38:51,920 surgical decompression may be needed. Let's move on to our scafloid or our navicular 574 00:38:51,920 --> 00:38:57,199 fracture. This is your most common carpal fracture. So scaffoid fractures are the 575 00:38:57,199 --> 00:39:00,440 most common carpon bone fracture. They're seen in around sixty to seventy percent of 576 00:39:00,559 --> 00:39:05,039 all carbal fractures, so that's an important one to know. That's often tested 577 00:39:05,119 --> 00:39:08,880 on mechanism. Another foocher so foosh fallen an outstretched hand will likely be the 578 00:39:08,920 --> 00:39:14,719 cause of a scafoid fracture, or really any other injury that involves an axial 579 00:39:14,760 --> 00:39:16,880 load placed on the wrist. On physical exam, they're obviously gonna have some 580 00:39:16,880 --> 00:39:20,559 pain in the wrist, But where is the pain going to be. It 581 00:39:20,639 --> 00:39:22,639 gonna be a few different places. It can be distal to the listers, 582 00:39:22,639 --> 00:39:27,559 tubercle, the volar prominence. But the only one that you have to know, 583 00:39:27,679 --> 00:39:30,159 the one that will ninety nine percent be how it's described in the vignette, 584 00:39:30,400 --> 00:39:36,039 will be pain or tenderness at the anatomic snuffbox. Know this for the 585 00:39:36,079 --> 00:39:40,000 exam. As soon as you hear anatomic snuffbox tenderness, be thinking scaffoid fracture 586 00:39:40,199 --> 00:39:45,599 always, so any tenderness in the snuffbox should be treated as a scaffoid fracture 587 00:39:45,960 --> 00:39:50,440 until proven otherwise. The snuffbox is located just proximal to the base of the 588 00:39:50,519 --> 00:39:53,239 thumb. Now diagnosis, you're gonna order a risk X ray. Obviously you 589 00:39:53,320 --> 00:39:58,400 want to include a scaffoid view. The thing about scaffoid fractures, though, 590 00:39:58,440 --> 00:40:00,760 is that they can be missed on X ray. Is pretty often X rays 591 00:40:00,800 --> 00:40:05,360 taken soon after the injury can be missed up to fifty four percent of cases, 592 00:40:05,440 --> 00:40:08,679 so half the time. So if the history and physical exam findings are 593 00:40:08,719 --> 00:40:14,239 suspicious for a scaffoid fracture but the X rays are negative, you're often gonna 594 00:40:14,280 --> 00:40:17,320 have to send these patients for a CTRMRI because if you miss a scaffoid fracture, 595 00:40:17,679 --> 00:40:21,480 the scaffoid, unfortunately has a crappy blood supply. And can be at 596 00:40:21,519 --> 00:40:24,400 risk for non union osteon necrosis. So if it fits the picture of a 597 00:40:24,400 --> 00:40:28,719 scaffoid fracture but the X rays are negative, you still treat it like a 598 00:40:28,760 --> 00:40:34,199 fracture until you can definitively say otherwise. Treatment thumb spike up. Treatment for 599 00:40:34,440 --> 00:40:37,760 majority of patients with a non displaced fracture or those patients who have negative X 600 00:40:37,840 --> 00:40:43,400 rays but have snuffbox tenderness, you give these patients a thumb spike until you 601 00:40:43,400 --> 00:40:45,960 can roll out a fracture with the scaffoid. Again, treat it like a 602 00:40:46,000 --> 00:40:51,880 fracture until you know it ain't surgery. If it's a displaced fracture or there's 603 00:40:51,920 --> 00:40:55,400 neurovascular compromise, surgical repair will be appropriate, but in most cases it's going 604 00:40:55,480 --> 00:40:59,119 to be your thumb spike of splint will be the answer. Choice. All 605 00:40:59,199 --> 00:41:02,599 right, let's talk about distal radius fractures are Colleagues versus our Smith fractures. 606 00:41:02,719 --> 00:41:06,159 There's really just a few things to know here, mainly just being able to 607 00:41:06,159 --> 00:41:09,800 differentiate between a Collie and a Smith fracture mechanism. Again, Foush, most 608 00:41:09,840 --> 00:41:14,840 common mechanism of the distal radius fracture is going to be falling on an outstretched 609 00:41:14,840 --> 00:41:19,920 hand. More of the more often the risk is going to be extended in 610 00:41:19,960 --> 00:41:23,119 a Collie fracture injury, and often you'll see it's flexed in a Smith fracture. 611 00:41:23,199 --> 00:41:29,039 So just a little side note there on physical exam, collies fractures have 612 00:41:29,159 --> 00:41:32,559 what's known as a dinner fork deformity, and this is due to the dorsal 613 00:41:32,639 --> 00:41:37,880 displacement of the distal fragment. Collige type fractures are often said to have this 614 00:41:37,960 --> 00:41:39,360 dinner fork appearance. If you want to see some pictures that have it in 615 00:41:39,360 --> 00:41:44,559 the YouTube video. And then Smith fractures are sometimes described as a garden spade 616 00:41:44,599 --> 00:41:47,440 deformity. Don't go too crazy memorizing these names dinner fork, garden spade, 617 00:41:47,480 --> 00:41:51,360 because they're likely not going to use these buzzwords. You just need to remember 618 00:41:51,440 --> 00:41:53,239 that one has dorsals displacement, the other has eventual displacement. I'm going to 619 00:41:53,280 --> 00:41:57,719 give you anemonic for that in a second, but remember, I guess Smith 620 00:41:57,760 --> 00:42:00,960 fracture sometimes known as a garden spade deform me, and that's if you see 621 00:42:00,000 --> 00:42:02,880 like a spade or a shovel and has this little bump on it, and 622 00:42:02,880 --> 00:42:07,000 that's because of the eventual displacement. It looks like that anyways. Diagnosis, 623 00:42:07,039 --> 00:42:09,440 this is what you really need to know. So when you take an X 624 00:42:09,559 --> 00:42:15,079 ray on a Collie's fracture, you're going to see dorsal displacement of the distal 625 00:42:15,159 --> 00:42:21,320 radius fracture, dorsal displacement of the disarradius fracture, and a Collie's fracture and 626 00:42:21,440 --> 00:42:25,039 a Smith fracture, you're going to see volar or palm our displacement of the 627 00:42:25,079 --> 00:42:31,400 distal radius fracture. So remember Collie's dorsal displacement Smith volar or palm our displacement 628 00:42:31,400 --> 00:42:35,719 of the distal radius fracture. That's the highest heal thing to know because this 629 00:42:35,880 --> 00:42:38,320 was differentiates the two and it may be the only difference in the vignette. 630 00:42:38,360 --> 00:42:43,360 So remember Collie's fractured, dorsal angulation of the radius, Smith fracture of volar 631 00:42:43,360 --> 00:42:46,639 angulation of the radius. The way that you remember that a Collie's fracture is 632 00:42:46,639 --> 00:42:52,079 dorsal displacement is because a Collie is actually a breed of a dog. Nice 633 00:42:52,119 --> 00:42:55,199 and conveniently it's the same dog that Lassie was on that show a number of 634 00:42:55,280 --> 00:42:59,679 years ago. So a Collie dog when you think of a Collie fracture, 635 00:42:59,719 --> 00:43:02,320 Think of a Collie dog and the first two letters in dog are the first 636 00:43:02,320 --> 00:43:08,079 two letters in dorsaldo. So this helps you remember Collie's fractures are doo dorsally 637 00:43:08,559 --> 00:43:14,920 dorsally alculated radial fractures and by method of exclusion, smith is the opposite volar 638 00:43:14,960 --> 00:43:19,360 angulated radial fractures. So when you see collie fracture, think of a Collie 639 00:43:19,400 --> 00:43:24,440 dog doo dorsal dog treatment splint splint, reduction for surgery. So some fractures 640 00:43:24,480 --> 00:43:30,199 can be treated with closed reduction sugar tongue splint. Other fractures are gonna require 641 00:43:30,199 --> 00:43:35,000 surgical or repair defend, depending on the severity. Remember your Collie dog dorsal 642 00:43:35,039 --> 00:43:37,719 angulation for your Collie fracture. Just knowing that one thing may get you the 643 00:43:37,800 --> 00:43:40,960 question. Very likely it will if you ever forget which side is the dorsal 644 00:43:42,000 --> 00:43:44,920 side of the hand or the risk. Remember the dorsal fin of a dolphin 645 00:43:45,039 --> 00:43:47,360 is on its back. Therefore, a fracture with dorsal angulation will be angulated 646 00:43:47,360 --> 00:43:51,960 for the back or the top of the wrist area. All right, lunate 647 00:43:52,039 --> 00:43:55,679 fractures. So, lunate fractures are pretty uncommon. Their only account for about 648 00:43:55,679 --> 00:43:59,800 four percent of all carpal bone injuries, but they do have some pretty serious 649 00:44:00,000 --> 00:44:04,480 applications if they're not treated. So mechanism of injury is going to be another 650 00:44:04,559 --> 00:44:08,079 fall on an extended wrist or any other type of risk hyper extension injuries. 651 00:44:08,280 --> 00:44:12,719 These are going to be your most common mechanisms of injuries for a lunar fracture 652 00:44:13,119 --> 00:44:15,199 diagnosis, so X ray. Main thing to know about X rays of the 653 00:44:15,239 --> 00:44:20,800 lunate is that they're missed quite often with playing radiographs. If there's any clinical 654 00:44:20,800 --> 00:44:24,360 suspicion, it's important to obtain vanced imaging like ctrmri CT is going to be 655 00:44:24,840 --> 00:44:29,079 preferred. One of the thing that I wanted to mention because it may come 656 00:44:29,119 --> 00:44:34,079 up if you have a dislocation of the lunate bone. The lunate gets displaced 657 00:44:34,119 --> 00:44:37,920 and angled in this volar direction and in comparison to the surrounding structure is the 658 00:44:37,960 --> 00:44:42,960 distal radius metacarpals which are all in normal alignment. It looks like a tea 659 00:44:43,000 --> 00:44:45,800 cup spilling over on lateral X rays, at least that's what they say, 660 00:44:45,840 --> 00:44:47,880 and it's called a spilled tea cup sign. So just in case, you 661 00:44:47,880 --> 00:44:52,079 hear that being mentioned at any point you'll know. This is what can be 662 00:44:52,119 --> 00:44:57,079 seen in a lunate dislocation. So you need to know a complication a vascular 663 00:44:57,159 --> 00:45:02,320 necrosis and kind box disease. So aggressive collapse of the lunate mechanism of injury 664 00:45:02,519 --> 00:45:06,920 is really unclear. This is kind box disease, so it's a progressive collapse 665 00:45:06,920 --> 00:45:12,280 of the lunate mechanism of mechanism is really unclear. It evolves to appear some 666 00:45:12,519 --> 00:45:15,760 disruption of the blood supply. It's likely related to undiagnosed fractures of the lunate. 667 00:45:16,480 --> 00:45:22,039 Some other complications with lunar fractures are complex regional pain, syndrome, osteoarthritis. 668 00:45:22,559 --> 00:45:27,800 Nothing specific I would know for the treatment for lunar fractures, except in 669 00:45:27,840 --> 00:45:30,960 the case of a dislocation, in which immediate reduction is really important to prevent 670 00:45:31,000 --> 00:45:36,760 a number of complications. So again that's your lunate fractures and a little bit 671 00:45:36,800 --> 00:45:39,920 about dislocations. Not a lot to know there. Let's talk about decoreving tendinopathy 672 00:45:40,039 --> 00:45:45,920 next. So this is a thickening of the abductor policis longest the apl and 673 00:45:46,079 --> 00:45:52,559 extensor policis brievious, the EPV tendons and the tunnel or the sheath and the 674 00:45:52,559 --> 00:45:59,679 first extensor compartment. So the abductor policis longest apl the extensor policies brievious EPB 675 00:45:59,800 --> 00:46:04,880 tends. They pass through this tunnel called the fibro osseous tunnel from the forearm 676 00:46:05,000 --> 00:46:08,519 into the hand, and any thickening of these tendons passing through here, or 677 00:46:08,599 --> 00:46:13,679 thickening of the tunnel itself can restrain the gliding motion through the sheath, which 678 00:46:13,679 --> 00:46:16,159 can lead to the clinical manifestations will go over. So think of a rope 679 00:46:16,199 --> 00:46:20,480 going through a little hole and the rope's getting bigger or the holes getting smaller. 680 00:46:20,480 --> 00:46:25,400 Eventually it's going to get stuck. I don't recommend memorizing abductor polysis longest 681 00:46:25,679 --> 00:46:30,440 an extensor polysis brevist. Those are hard enough to say. It's just too 682 00:46:30,519 --> 00:46:35,199 much brainpower to memorize those complicated names. What I would recommend memorizing, though, 683 00:46:35,639 --> 00:46:38,239 is apples with extra peanut butter are delicious, because if you can remember 684 00:46:38,559 --> 00:46:45,880 that apples spelled apl apl as an APL tendon with extra peanut butter EPB as 685 00:46:45,880 --> 00:46:51,119 an EPB tendon are delicious as in decore vein tendinopathy. If you can remember 686 00:46:51,159 --> 00:46:55,360 that, that helps you remember your APL tendon and your EPB tendon are going 687 00:46:55,400 --> 00:47:01,360 to be involved in this decorvein sendingpathy, and this should be enough for you 688 00:47:01,400 --> 00:47:05,400 to be able to pick them out on the multiple choice question by remembering the 689 00:47:05,480 --> 00:47:07,840 letters involved in the full name. So if you can remember abductor policies as 690 00:47:07,840 --> 00:47:12,039 long as an extensor policies breathes, in addition of the twenty thousand other things 691 00:47:12,079 --> 00:47:14,760 you need to for PA school, more power to you. But I just 692 00:47:14,800 --> 00:47:16,679 remember apples with extra peanut butter are delicious. That was enough for me to 693 00:47:16,679 --> 00:47:21,840 help pick out the right answer on my clinical medicine exam. So apples again, 694 00:47:21,920 --> 00:47:25,880 APL, extra peanut butter EPB are delicious. Decorva intentanopathy. You're done, 695 00:47:27,119 --> 00:47:29,880 all right, So what about the patient demographic you're looking for? So 696 00:47:30,719 --> 00:47:35,880 you are going to be looking for women between the ages of thirty to fifty 697 00:47:35,960 --> 00:47:38,320 years of age, and then it's also prevalent in a subset of women in 698 00:47:38,320 --> 00:47:43,320 the postpartum period. Symptoms usually going to present about four to six weeks after 699 00:47:43,400 --> 00:47:45,599 delivery. There's a lot of theories why this happens in the postpartum period, 700 00:47:46,599 --> 00:47:51,480 repetitive motion of the hands required to lift and hold newborns, hormonal causes for 701 00:47:51,559 --> 00:47:53,880 fluid retention, whatever the case. In the vignette, you're looking for both 702 00:47:53,920 --> 00:47:59,960 women in the thirty to fifty year age range and also postpartum women clinical menifs 703 00:48:00,039 --> 00:48:01,679 stations, they're going to have pain at the radial side of the wrist. 704 00:48:02,000 --> 00:48:06,000 It's going to be worse with thumb and wrist movement. So the tendons we 705 00:48:06,000 --> 00:48:08,199 went over before, the EPB in the apple, the EPP in the apple, 706 00:48:08,480 --> 00:48:13,960 the EPB and the APL are responsible for movement of the thumb, So 707 00:48:14,000 --> 00:48:15,440 you can imagine a lot of the complaints are going to be related to thumb 708 00:48:15,440 --> 00:48:19,199 movements, and so the EPB and the APL are responsible for movement of the 709 00:48:19,239 --> 00:48:25,880 thumb. Diagnosis so decavent tendonopathy is based upon the history of an atraumatic radial 710 00:48:27,000 --> 00:48:30,079 wrist pain and positive physical exam findings, So imaging like X ray is not 711 00:48:30,119 --> 00:48:35,079 really necessary except to rule out other differentials which may have a similar presentation like 712 00:48:35,119 --> 00:48:39,519 osteoarthritis. The main thing to know for diagnosis is a physical exam maneuver called 713 00:48:39,559 --> 00:48:45,440 the Finkel steam test. So the Finkel steam provocation test involves the patient wrapping 714 00:48:45,440 --> 00:48:50,800 their fingers around their thumb, clasping it in their palm, and then you 715 00:48:50,840 --> 00:48:54,199 apply ulnar deviation to the wrist. If they have pain over the radio styloid 716 00:48:54,239 --> 00:48:58,519 area so the basic of the thumb, this is considered a positive test. 717 00:48:58,559 --> 00:49:01,800 Again, that's the Finkel Steing test. Treatment thumb spike a splints going to 718 00:49:01,840 --> 00:49:07,119 be the big one and SAIDs google cordecoid injections. So decoving tendonopathy is generally 719 00:49:07,159 --> 00:49:13,400 non progressive. It's typically self limited, so most of your conservative measures are 720 00:49:13,400 --> 00:49:15,440 going to be your mainstay. Again, thumb spike a splint is commonly used, 721 00:49:15,639 --> 00:49:21,239 and said steroid injection surgery really is going only to be for refractory cases. 722 00:49:22,519 --> 00:49:25,440 Talk about mallet fingernecks. So this is a finger deformity caused by traumatic 723 00:49:25,480 --> 00:49:30,920 disruption of the terminal slip of the extensor tendon at the distal interfalangeal joint, 724 00:49:30,960 --> 00:49:35,119 so the dip joint. So you have some sort of trauma to the finger, 725 00:49:35,280 --> 00:49:37,400 usually caused by a direct blow to the tip of the finger, so 726 00:49:37,519 --> 00:49:42,960 maybe a ball striking the fingertip or the fingertip strikes a hard surface. The 727 00:49:43,039 --> 00:49:47,119 trauma causes a tear in the extensor tendon at the dip joint. And this 728 00:49:47,199 --> 00:49:52,119 is the tendon that allows you to extend your fingers so to hold them out 729 00:49:52,159 --> 00:49:53,840 straight, and with this being torn, you can no longer do that, 730 00:49:53,840 --> 00:49:59,000 so the finger remains in this constant slit state of flexion. Now on physical 731 00:49:59,039 --> 00:50:01,480 exam, they're going to have an inability to extend the dip joint. This 732 00:50:01,519 --> 00:50:06,000 is going to result in that flex DP So it's really simple. Patient's going 733 00:50:06,039 --> 00:50:08,039 to have this constant flection of the dip joint. They're not going to be 734 00:50:08,079 --> 00:50:13,920 able to extend the finger at that joint. This specific degree of the dip 735 00:50:14,000 --> 00:50:17,760 angulation is often going to reflect the severity of the tendon disruption. Now diagnosis 736 00:50:19,000 --> 00:50:22,480 X ray. So in some cases with the mallet finger, you're going to 737 00:50:22,559 --> 00:50:25,480 visualize a bony evulsion of the distal failings at the site where the tendon attaches. 738 00:50:25,719 --> 00:50:30,239 It just got ripped off during the injury. It's also possible just to 739 00:50:30,320 --> 00:50:34,480 have just a ligamentous injury with normal bony anatomy, so you can see either 740 00:50:34,519 --> 00:50:38,679 one. Now, treatment really important extension splinting of the dip joint for six 741 00:50:38,760 --> 00:50:44,639 to eight weeks with twenty four hours of maintaining this extension, So the dip 742 00:50:44,760 --> 00:50:50,119 joint must be maintained at full extension throughout the entire period, including during sleep. 743 00:50:50,440 --> 00:50:52,840 If the joint extension is lost at any point during this initial treatment period, 744 00:50:52,960 --> 00:50:57,320 the treatment clock is reset and an additional six weeks of splinting has to 745 00:50:57,360 --> 00:51:00,719 be performed. So if you think about it, you're keeping those horn tendon 746 00:51:00,840 --> 00:51:04,800 edges aligned. So as soon as you bend that finger just rips it tears 747 00:51:04,840 --> 00:51:07,639 all over again. So the only wayfer it to completely heal is to have 748 00:51:07,679 --> 00:51:10,880 that finger in full extension with the torn ligament aligned for six to eight weeks. 749 00:51:13,000 --> 00:51:16,079 The majority of malletfingers are amendable to treatment with just splinting. Surgery is 750 00:51:16,079 --> 00:51:21,000 really only going to be a reserved for large displaced fractures or other complex injuries 751 00:51:21,559 --> 00:51:24,079 that may warrant with surgical referral. But really focus on splinting as that's going 752 00:51:24,119 --> 00:51:28,280 to be your most common, your main state treatment. So maletfinger again, 753 00:51:28,360 --> 00:51:32,480 extensor extensor tendon injury. Dip joint now flex all of the time. They 754 00:51:32,519 --> 00:51:36,960 can't extend it, straighten it out with a splint done. That's your mallet 755 00:51:36,960 --> 00:51:43,400 finger. Let's talk about ulnar collateral ligament injury aka a gamekeeper or skiers thumb. 756 00:51:43,440 --> 00:51:46,400 It's an injury caused by damage to the ulnar collateral ligament of the thumb. 757 00:51:46,719 --> 00:51:52,239 Mechanism of injury is going to be a forced abduction, abduction and hyper 758 00:51:52,280 --> 00:51:55,159 extension of the thumb. This is going to be at the metacarpul philangial joint. 759 00:51:55,519 --> 00:51:59,440 That's going to be your most common cause. So the thumb is stretched 760 00:51:59,719 --> 00:52:04,400 and forced into extreme abduction, whether this is from a fall and athletic injury 761 00:52:04,760 --> 00:52:08,599 skiing accidents where the thumb strikes a fixed ski pull, and that's where the 762 00:52:08,719 --> 00:52:14,639 names skier stumb came from or the name gamekeeper stumb, so not so relevant 763 00:52:14,679 --> 00:52:19,679 anymore. But basically this was this chronic degeneration of the owlner collateral ligament from 764 00:52:19,719 --> 00:52:22,519 twisting the necks of too many birds and rabbits. So I'm making that up. 765 00:52:22,519 --> 00:52:25,760 That's what gamekeeper stumb came from. So yeah, probably won't be the 766 00:52:25,800 --> 00:52:29,800 reason why your patient comes in with this, but seventy plus years ago when 767 00:52:29,800 --> 00:52:31,960 the name was created, it was today most often this is going to be 768 00:52:32,000 --> 00:52:37,280 a skiing related injury or another athletic related injury. On physical exam, you 769 00:52:37,280 --> 00:52:40,920 can pretty much confirm a UCL injury with your physical exam findings combined with your 770 00:52:40,960 --> 00:52:46,480 appropriate clinical manifestations. So Valgus stress testing is going to reveal a loss of 771 00:52:46,519 --> 00:52:52,480 integrity of the UCL, so the injured thumb will have increased laxity of the 772 00:52:52,559 --> 00:52:54,800 MCP joints, so the thumb you're going to be able to pull much further 773 00:52:54,880 --> 00:53:00,360 away compared with the uninjured thumb. When Valgus stress is applied, the test 774 00:53:00,400 --> 00:53:05,039 is positive and the patient has the classic clinical manifestations paintings ascerbated by thumb extension 775 00:53:05,440 --> 00:53:08,360 or abduction, and swelling along the owner aspect of the thumb at the MCP 776 00:53:08,480 --> 00:53:13,360 joint. This is going to help to confirm the diagnosis, but you also 777 00:53:13,400 --> 00:53:16,239 want to get an X ray of the thumb to rule out any possible bony 778 00:53:16,280 --> 00:53:22,039 evulsion, fractures and definitive diagnosis can be made with an MRI or ultrasound, 779 00:53:22,039 --> 00:53:25,320 but generally it's not necessary treatment. Thumb spike is splint so a mobilization with 780 00:53:25,360 --> 00:53:30,199 the thumb spika will be sufficient in most patients. Some patients with a complete 781 00:53:30,199 --> 00:53:36,920 tear or patients that don't respond to conservative therapy may require surgical intervention. Boxer's 782 00:53:36,960 --> 00:53:39,800 fracture. This one's pretty much straightforward. It's a fracture of the fifth metacarpal 783 00:53:39,880 --> 00:53:45,559 neck. Generally the fifth metacarpal neck fractures when we're talking about boxer fractures. 784 00:53:45,760 --> 00:53:49,639 Occasionally sometimes we'll hear being referred to fractures of the fourth metacarpal as well. 785 00:53:49,679 --> 00:53:53,880 But now it's common mechanism of injury direct trauma to a clenched fist. So 786 00:53:53,960 --> 00:53:58,760 obviously the most common situation where you're gonna have direct trauma to a closed finch 787 00:53:59,039 --> 00:54:04,079 or just say a clenched fist would be punching something, so that's going to 788 00:54:04,119 --> 00:54:07,320 be the most common cause. So whether they're punching a wall, a solid 789 00:54:07,360 --> 00:54:10,320 object, a face, that's why it's called a boxer's fracture. In reality, 790 00:54:10,360 --> 00:54:15,800 though experienced boxers actually rarely sustained this type of fracture. It's more the 791 00:54:15,840 --> 00:54:20,400 wild roundhouse punching motion that's common in street fights that cause this, Or someone 792 00:54:20,400 --> 00:54:22,920 who punched a brick wall who's going to come in with this type of fracture, 793 00:54:22,239 --> 00:54:25,280 rather than in a floyd Mayweather who's trained to punch the right way. 794 00:54:27,440 --> 00:54:30,639 Diagnosis are going to be made with X ray so plaine radiographs of the hand. 795 00:54:30,880 --> 00:54:35,000 This is going to establish the diagnosis of a metacarpal neck fracture and this 796 00:54:35,039 --> 00:54:38,239 will also help to determine the degree of the fracture angulation. So treatment is 797 00:54:38,280 --> 00:54:44,519 going to be with a mobilization with an gut or splint. So gut or 798 00:54:44,519 --> 00:54:49,320 splint is going to be It's going to be used to mobilize fractures of both 799 00:54:49,360 --> 00:54:52,800 the fourth and the fifth metacarpal necks. If the patient does have an open 800 00:54:52,880 --> 00:54:58,880 fracture, a severely common unit fracture, or if they have significant angulation normally 801 00:54:58,920 --> 00:55:01,360 over thirty to four where your degrees, this is going to require surgical consult 802 00:55:01,840 --> 00:55:06,000 Otherwise, immobilize it with a splint. All right, let's finish up with 803 00:55:06,039 --> 00:55:08,079 something a little bit different, and because I feel like I can no longer 804 00:55:08,119 --> 00:55:12,760 talk, keep getting stumbling on my words, let's finish up with complex regional 805 00:55:12,760 --> 00:55:16,199 pain syndrome. So this is an array of painful conditions that are characterized by 806 00:55:16,599 --> 00:55:22,920 a continuing regional pain that is seemingly disproportionate in time or degree to the usual 807 00:55:23,000 --> 00:55:29,159 course of any known trauma or other lesion. That's the official definition. So 808 00:55:29,199 --> 00:55:32,760 basically, these patients have this prolonged pain. It's completely disproportionate to the initiating 809 00:55:32,800 --> 00:55:37,800 event. Most frequently this is going to follow a bone or soft tissue injury. 810 00:55:37,079 --> 00:55:40,079 So most cases there's going to be some sort of injury sprain, fracture, 811 00:55:40,079 --> 00:55:45,039 et cetera. In some cases there may be no precipitating factor. It's 812 00:55:45,039 --> 00:55:49,079 not common, and then weeks later they're going to start to develop this range 813 00:55:49,079 --> 00:55:52,840 of clinical manifestations, autonomic dysfunction, pain out of proportion to the initial injury, 814 00:55:53,119 --> 00:55:57,119 hair and nail changes. The path though, is really unknown, and 815 00:55:57,119 --> 00:56:00,639 there's some proposed mechanisms, but definitely nothing to know for the exam. Now, 816 00:56:00,679 --> 00:56:04,880 in clinical manifestations, this is the most important thing about complex regional pain 817 00:56:04,960 --> 00:56:07,880 syndrome. It's the presentation. The diagnostic criteria is low yield, the treatments 818 00:56:07,880 --> 00:56:12,960 low yield. It's all about being able to recognize the clinical manifestations. That's 819 00:56:13,000 --> 00:56:15,559 what you need to know for the exam. So the main clinical manifestations of 820 00:56:15,599 --> 00:56:22,440 complex regional pain syndrome are pain, sensory changes, motor impairments, autonomic syntoms 821 00:56:22,480 --> 00:56:25,360 and trophic changes in the affected limb. This is usually going to occur four 822 00:56:25,400 --> 00:56:30,440 to six weeks after the inciting event. The reason I'm covering this under the 823 00:56:30,480 --> 00:56:34,239 upper extremity section for the pants is because this most commonly occurs in the upper 824 00:56:34,280 --> 00:56:37,599 extremity around sixty percent of the time. So the way that I used to 825 00:56:37,639 --> 00:56:42,119 remember the common clinical manifestations that you're going to see in a vignette for complex 826 00:56:42,199 --> 00:56:46,199 regional pain syndrome is by remembering instead of complex regional pain syndrome, I want 827 00:56:46,199 --> 00:56:52,840 you to remember complex regional paint syndrome. So PAI nt complex regional paint syndrome. 828 00:56:53,079 --> 00:56:57,760 And what does paint stand for? So paint stands for the P stands 829 00:56:57,760 --> 00:57:00,360 for perspiration, and this is due to the auto aconomic dysfunction, so forty 830 00:57:00,360 --> 00:57:05,960 percent of patients are going to experience increased sweating on the side where they're experiencing 831 00:57:06,000 --> 00:57:09,800 this. The A in paint stands for after injury, So after injury for 832 00:57:09,840 --> 00:57:14,760 the A, because remember this is most commonly going to take place after some 833 00:57:14,800 --> 00:57:16,960 sort of bone or soft tissue injury, So look for some sort of injury 834 00:57:16,960 --> 00:57:22,840 mentioned in the vignette weeks prior the eye, and PAINT stands for inappropriate pain 835 00:57:22,199 --> 00:57:27,400 because remember the pain experience is inappropriate, it's out of proportion to the initial 836 00:57:27,440 --> 00:57:31,760 injury. Pain is typically the most prominent in debilitating symptom of complex regional pain 837 00:57:31,800 --> 00:57:37,360 syntems. So remember I stands for inappropriate pain because it's not appropriate to have 838 00:57:37,360 --> 00:57:38,599 ten out of ten pain in your risk from a sprain you had two months 839 00:57:38,639 --> 00:57:44,360 ago, So remember inappropriate pain for I. The END stands for nail changes. 840 00:57:44,559 --> 00:57:47,480 So remember I talked about before your trophic changes, so these patients may 841 00:57:47,519 --> 00:57:52,559 have increased or decreased nail growth. Also look for hair growth changes as well, 842 00:57:52,559 --> 00:57:55,159 but remember END stands for nail changes from your trophic changes. And then 843 00:57:55,199 --> 00:58:00,719 the last letter T and paint stands for temperature changes. This relates back to 844 00:58:00,760 --> 00:58:04,400 those autonomic changes. Again, these patients can have and some patients are going 845 00:58:04,440 --> 00:58:07,760 to see a difference in skin temperature and the affected side versus the unaffected side 846 00:58:08,159 --> 00:58:13,199 of over one degree celsius. So remember if you have a vignette you think 847 00:58:13,239 --> 00:58:17,519 the patient they're talking about may have complex regional pain syndrome. Remember to look 848 00:58:17,519 --> 00:58:23,920 for paint perspiration after injury and appropriate pain, nail changes, temperature, changes, 849 00:58:24,119 --> 00:58:27,519 and that should be enough to get you there and get the right answer. 850 00:58:27,800 --> 00:58:31,960 Now, diagnosis clinical features based on your H ANDP, So the diagnosis 851 00:58:32,000 --> 00:58:37,159 is really just based upon the clinical features determined by your history and physical So 852 00:58:37,360 --> 00:58:39,840 nothing really to know for the exam question. You're basically looking to see are 853 00:58:39,880 --> 00:58:45,039 they having pain, sensory changes, motor symptoms, autonomic dysfunction? Are these 854 00:58:45,039 --> 00:58:49,559 symptoms weeks out from an initial injury that would no longer be appropriate to persist 855 00:58:49,599 --> 00:58:52,880 at this point in time. There are some imaging tests that can be used 856 00:58:52,960 --> 00:58:57,039 three phase bone syntigraphy, radiographs, but there's nothing high yield, there's no 857 00:58:57,119 --> 00:59:00,400 gold standard tests. Definitely nothing I would memorize for the exam, So just 858 00:59:00,440 --> 00:59:05,000 know this is generally clinical diagnosis. Are the experiencing paint? If so? 859 00:59:05,239 --> 00:59:13,559 Complex regional pain syndrome treatment it's multifaceted physical therapy and SAIDs tricyclic antidepressence, sympathetic 860 00:59:13,599 --> 00:59:17,800 nerve blocks. Physical and occupational therapy are more or less considered first line treatment 861 00:59:19,159 --> 00:59:23,440 for complex regional pain syndrome. But again it's a multifaceted, multi disciplinary approach. 862 00:59:23,480 --> 00:59:27,920 There's not one specific thing to know for treatment. The main takeaway for 863 00:59:28,000 --> 00:59:35,280 complex regional pain syndrome. To identify in a vignette is to remember the symptoms 864 00:59:35,320 --> 00:59:37,840 that you're seeing in these patients. The treatments really not high yield. Diagnostic 865 00:59:37,840 --> 00:59:42,079 criteria is really not that high yield. It's being able to recognize it in 866 00:59:42,119 --> 00:59:46,159 a vignette. So remember complex regional paint syndrome, perspiration after injury, inappropriate 867 00:59:46,239 --> 00:59:50,639 pain, nail changes, temperature changes. That's the main takeaway here, and 868 00:59:50,760 --> 00:59:53,199 we are done with the upper extremity. Let's do five quick questions. Question 869 00:59:53,239 --> 00:59:57,920 one, thirty two year old female presents the office complaining of pain at the 870 00:59:58,039 --> 01:00:01,119 radial sign of her wrist that is most prominent upon movement of the thumb. 871 01:00:01,400 --> 01:00:07,039 She has four weeks postpartum. Pasthematical history is otherwise unremarkable. On exam, 872 01:00:07,039 --> 01:00:10,800 tenderness is noted over the radial styloid and pain. His experience with passive ulner 873 01:00:10,840 --> 01:00:15,599 deviation of the wrist with the thumb flexed in the palm. What is the 874 01:00:15,679 --> 01:00:20,039 likely diagnosis in this patient? So that is going to be decore vain tendinopathy. 875 01:00:20,400 --> 01:00:23,800 So decarevyin tendonopathy we know is most commonly seen in women between the thirty 876 01:00:23,840 --> 01:00:29,199 to fifty year age rage also common to see and postpartum women four to six 877 01:00:29,239 --> 01:00:32,079 weeks after delivery. So she fits this criteria to the tea. Then she 878 01:00:32,119 --> 01:00:35,559 states she has pained on the radio side of the wrist, and then a 879 01:00:35,559 --> 01:00:38,639 physical exam tenderness over the radio styloid. She has a positive Finkelstein test for 880 01:00:38,760 --> 01:00:44,119 the patient's wrist as put into Olnar deviation. All the patient's fingers are folded 881 01:00:44,159 --> 01:00:47,800 over the thumb. This is a classic presentation for decorevain tendeonopathy. Question two. 882 01:00:47,880 --> 01:00:52,199 A forty three year old female presents at the office complaining of numbness and 883 01:00:52,320 --> 01:00:55,960 tingling in her hands, mostly affecting the thumb, index and middle finger, 884 01:00:57,199 --> 01:01:00,519 and part of the ring finger. She states it is worse at nights, 885 01:01:00,559 --> 01:01:04,400 sometimes awaking her from sleep. Both a Tannell and a Palin test are positive. 886 01:01:04,400 --> 01:01:08,119 On physical exam. His patient is likely experiencing compression of which nerve, 887 01:01:08,480 --> 01:01:12,559 so that is going to be the median nerve. So this patient is experiencing 888 01:01:12,599 --> 01:01:15,480 carpal tunnel syndrome, which is compression of the medial nerve median nerves. So 889 01:01:15,519 --> 01:01:20,280 we know this because the patient parastages in the median nerve. Territory, which 890 01:01:20,320 --> 01:01:22,920 will be the first three fingers and radial half of the fourth. In addition, 891 01:01:22,960 --> 01:01:27,239 she states it's worse at night, which is very common for carpal tunnel. 892 01:01:27,559 --> 01:01:30,039 Finally, we have a positive Tannell and Phalin test that seals the deal. 893 01:01:30,280 --> 01:01:34,679 We know this is carpal tunnel, which is median nerve compression. Question 894 01:01:34,760 --> 01:01:37,639 three. Twenty seven year old Mail presents to the er after a bicycle accident 895 01:01:37,679 --> 01:01:40,840 he had earlier on in the day. He states his bike hit a pothole 896 01:01:40,880 --> 01:01:45,039 which sent him flying off his bike, landing onto his outstretched hands. He's 897 01:01:45,079 --> 01:01:50,280 now complaining of pain along the radial side of the wrist and is tender just 898 01:01:50,440 --> 01:01:55,039 proximal to the base of the thumb at the anatomic snuffbox fracture of which bone 899 01:01:55,280 --> 01:01:59,920 should be suspected. And this patient until proven otherwise, so that is going 900 01:02:00,000 --> 01:02:02,599 to be the scaffoid. This is a simple one scaffoid or avicular fracture. 901 01:02:02,639 --> 01:02:06,519 You have a patient had to fall into an outstretched hand, which is often 902 01:02:06,559 --> 01:02:08,239 the mechanism of injury for a scaffoid fracture, and he has pain on the 903 01:02:08,320 --> 01:02:13,119 radial side of the wrist. Snuffbox tenderness. You are done. That is 904 01:02:13,119 --> 01:02:16,079 a scaffoid fracture until proven Otherwise, as soon as you hear snuffbox, always 905 01:02:16,079 --> 01:02:21,519 be thinking of a scaffoid fracture. Question four. Sixty seven year old Mail 906 01:02:21,559 --> 01:02:24,559 presents to the office today complaining of persistent elbow pain. He does not recall 907 01:02:24,599 --> 01:02:29,039 any trauma to the elbow, but the painting he is experiencing in his elbow 908 01:02:29,119 --> 01:02:31,639 is affecting his golf game, as he is an avid golfer. On exam, 909 01:02:31,679 --> 01:02:37,280 pain is elicited by performing risk flection against resistance. Tenderness would likely be 910 01:02:37,320 --> 01:02:42,360 felt in which part of the elbow in this patient, so that would be 911 01:02:42,400 --> 01:02:46,039 at the medial epicondyle. So you have a classic case of medial epicondolitis aka 912 01:02:46,159 --> 01:02:50,679 golfer's elbow. If you have a sixty seven year old male avid golfer with 913 01:02:50,800 --> 01:02:53,239 elbow pain, no preceding trauma, and then the key is that the pain 914 01:02:53,360 --> 01:02:58,440 is reproduced on exam with the risk being flexed against resistance. So in this 915 01:02:58,480 --> 01:03:01,360 case the patient wouldn't have pain and the medial epicondyle. And then of course 916 01:03:01,360 --> 01:03:05,679 remember the demonic mini golf is fun and in mini helps you Remember this is 917 01:03:05,679 --> 01:03:09,599 the media up a condal involved in golfer golfer's elbow golfs because this is known 918 01:03:09,679 --> 01:03:13,559 as golfer's elbow. And then the f and fun helps you remember this is 919 01:03:13,559 --> 01:03:17,039 going to involve flection, whether it's pain as pain with risk, flection against 920 01:03:17,039 --> 01:03:22,239 resistance on exam the fact that it involves the flex or copper radialis or that 921 01:03:22,280 --> 01:03:25,119 it's caused from repetitive flection. Mini golf is fun helps you remember all the 922 01:03:25,159 --> 01:03:28,719 things that you need to know. And then by method of exclusion, you 923 01:03:28,760 --> 01:03:32,320 know lateral epicond of lytis is the opposite problems with extension not flection. Last 924 01:03:32,400 --> 01:03:37,400 question question five. Seventeen year old Mail presents to the er after sustaining an 925 01:03:37,400 --> 01:03:39,920 injury to his right arm. After X rays are complete, the attending physician 926 01:03:39,960 --> 01:03:45,519 assistant and forbs him that the X ray revealed a proximal owner fracture accompanied by 927 01:03:45,559 --> 01:03:52,679 a radial head dislocation. This type of injury is also known as a and 928 01:03:52,719 --> 01:03:57,440 that is going to be a Montegia fracture. So remember grew some murder Montegia 929 01:03:57,519 --> 01:04:01,400 and Galiazzi fracture grew some first lead letters in russom stand for Galiazzi our stands 930 01:04:01,400 --> 01:04:05,960 for radius fracture, U stands for owning dislocation aka the radio owner joint, 931 01:04:06,039 --> 01:04:11,920 and then murder, which is the first three letters mu R montigia U stands 932 01:04:11,920 --> 01:04:15,719 for owner fracture, and our stands for radiohead dislocation, which is the type 933 01:04:15,719 --> 01:04:17,480 of injury we see here in this patient. All right, that is the 934 01:04:17,559 --> 01:04:20,800 upper extremity for the MSK section for the pants. Thank you so much for 935 01:04:20,840 --> 01:04:25,400 listening to the podcast, and good luck on you in paschool. Good luck 936 01:04:25,400 --> 01:04:27,760 on your pants or pantry ears, and thank you again