Okay, so let's do a CRAM session for MSK upper extremity. As always,
I'm going to stick to the need to know stuff. I'm not going
to bother your time with the stuff that I really feel is very low yield
and that you don't need to know. So let's go ahead and get started.
As always, thank you so much for the really nice comments. You
guys are just the nicest people, So thank you so much. Let's go
ahead and start with the shoulder and they'll work our way down. So anterior
gleno humeral dislocation, so this is your most common type. Anterior dislocation is
going to account for around ninety five to ninety seven percent of cases of shoulder
dislocations. Now, as far as the mechanism of injury, it's going to
be a blow to the abducted, externally rotated and extended arm. So that's
the most common mechanism of injury. So think like blocking a basketball shot your
arms up and out. Less commonly is going to be a blow to the
posterior humorous or a fault on an outstretched arm can also cause an anterior dislocation,
but focus on that arm being abducted. Abducted away from the body,
extended and externally rotated, and then something hitting the arm in that position.
Non physical exam. You need to know that you're looking for an abducted,
abducted externally rotated arm, So an anterior dislocation of the shoulder causing the arm
to be slightly abducted and externally rotated. Diagnosis, you're going to do an
X ray. X ray of the shoulder is normally going to be enough to
diagnose. Going to get an ap view, scapular y view, axillary view.
A few associated injuries you should know with an anterior dislocation. There's the
hill Sacks, bank art lesions, axillary nerve injury. It wouldn't go crazy
memorizing the specific injuries what they involved. Just know they're associated with anterior dislocation
hill sacks real quick. It's a cortical depression. Hill sax lesion is a
cortical depression in the humoral head made by the glenoid rim. Bank art legions
occur when the glenoid labrim is disrupted during the dislocation, and a bone fragment
is a vols and an axillary nerve injury. This one's probably the most important
associated injury to know. So it's really important to assess the nerve vascular status
in patients with an anterior shoulder dislocation because axillary nerve disfunction can actually show up
to up to forty two percent of patients with an anterior dislocation. So you're
gonna look for a loss of sensation on what's called the shoulder bags distribution.
It's basically like on a cop uniform or a military uniform. Just think of
the area of the arm that the shoulder badge would be. Where they have
a badge on the arm. That's where the axillary nerve innervates, and that's
where they may have this loss of sensation. They may also have deltoid muscle
weakness. So just be familiar that axillary nerve dysfunction is common in anterior dislocations.
As far as treatment reduced in sling, there's not much to know here,
certainly nothing to memorize. You reduce the dislocation, mobilize it with the
sling, and then assess for axillary nerve dysfunction pre and post reduction. Okay,
so there's a lot of random things to know for anterior dislocations. So
the way that you're going to remember them is by remembering a guy named Antonio.
So this is visualization times is much easier on the YouTube channel. I
have a nice little picture I'm made in MS paint, but let's just try
to visualize this. So Antonio is this guy and in one hand he's holding
a picture and in the other hand he's holding an axe. The picture that
he's holding is a bank on top of a hill like this nice pretty hill
with a sunset in the background. And then there's a bank sitting on top
of the hill. That's the picture. The other hand he's holding an axe.
Now he's holding both of these up and out by his sides. His
arms are abducted and they're externally rotated. So Antonio helps you to remember this
as an anterior dislocation. Antonio anterior dislocation. The picture that he's holding with
the bank on top of a hill helps you remember bank art lesions and hill
sack lesions that can commonly be seen in anterior dislocations. And then the axe
he's holding in his other hands helps you remember axillary nerve dysfunction that's the most
common in anterior dislocations. And then finally, the position of his arms.
Like I said, they're abducted and externally rotated. That helps you remember both
the way the arms usually positioned during the physical exam and during the injury too.
So remember a guy named Antonio holding a picture of a bank on top
of a hill on one hand holding an axe, and the other both arms
are abducted and externally rotated. And that should be all you need to know
for anterior dislocations for the exam, moving onto posterior glenohumeral dislocation. So these
are much less common compared to anterior They only occur in around two to four
percent of patients. Mechanism of injury for anterior dislocations wasn't very high yield,
but for posterior dislocations it is, and it's because it's unique. And if
you listen to any of my other content, you always know anytime there's something
unique, they're going to ask you questions about it, So keep that in
mind. Mechanism for posterior dislocations is going to be seizure and electric shock,
so those are the ones that you need to know. Of course, trauma
like a blow to the anterior portion of the shoulder can cause a posterior dislocation,
But what you should focus on is violent muscle contractions following a seizure or
electrocution, because those are the unique components that they like to ask questions about
seizure or electric shock. Remember those for your mechanism of injury in a posterior
dislocation. Now physical exam opposite of anterior So for a posterior dislocation, it's
going to be adducted and internally rotated. So usually the patient's going to hold
their arm in adduction and internal rotation and is usually unable to externally rotate again.
And that's different than anterior dislocations, which was abducted, abducted and externally
rotated. Now, diagnosis, you're going to get an X ray, so
you'll do your normal routine shoulder views, apyve you, etc. But be
aware of the light bulb sign on posterior dislocations because they may ask about this.
So on the AP view, the humoral head is going to be internally
rotated and because of this, the twoberocities of the humorous they're not going to
be visible. They're going to be normally, they're project out laterally, but
they're not going to be visible because the humoral heads internally rotated. And because
of this, I have to take my word for it, the humoral head
kind of takes on the circular appearance and supposedly looks like a light bulb.
I guess it kind of does. So anyways, if you hear a light
bulb sign, be thinking. Posterior dislocation treatment is going to be the same
as an interior You're going to reduce and sling. Okay, So for posterior
dislocation, there's a few things that you need to know. Remember your caesar
seizure and shock can be the mechanism of action, mechanism of injury. Remember
the arm is likely going to be adducted and internally rotated. And remember the
light bulb sign. Those are the high yel things. And the way that
you remember that is I want you to visualize this warning on a poster board.
So on the posterboard there's going to be a picture, and on the
posterboard there's going to be a picture of a broken light bulb. There's going
to be a finger, and then there's going to be a picture of a
guy being shocked. And it says if you add your finger into a broken
light bulb, you'll get shocked, So add an into if you add your
finger into, that helps you remember adducted and internal rotation. So if you
add your finger into adducted internal rotation, remember that's the most common presentation,
the broken light bulb, because you remember the light bulb sign on X ray
scene of posterior dislocations and shocked because remember the unique mechanism of injury, electric
shock, and seizure. And then again this is all on a posterboard because
that posterboard helps remember posterior dislocation. So again, remember a poster board,
and on the poster board it says if you add your finger into a broken
light bulb, you'll get shocked. Visual a posterboard with a finger a plus
sign, a broken light bulb and a guy being shocked, and you'll remember
everything you need to know for posterior dislocations. All right, moving on to
a rotator cuff injury. This is definitely a high heel topic. There's a
good deal to know for this, and you'll likely get a question on this.
So let's go over a rotator cuff tears and impingement. So first,
you need to know your muscles in the rotator cuff. I'm sure you've all
heard of the famous mnemonic sits S I S so superspinatus infraspinatus tarifs minor and
subscapularis mechanism of injury for rotator cuff. Injury is going to be a few
different things. So degeneration like chronic degenerative tear that's usually going to be seen
in older patients. Impingement. Chronic and pingement can also lead to a tear
and then overload, so like tension overload and athletes are continually throwing like in
baseball or jobs with repetitive overhead movement. In general, the cause of rotator
cuff tears, it's multifactorial degeneration and pingement, over they can all contribute.
There's not really anything I'd say is super important to memorize. The high yield
things for a rotator cuff is going to be the presentation of physical exam tests,
so clinical manifestations. There's two things to know here. Overhead pain and
pain at night. That's the key. So pain exacerbated by overhead activities.
So the vignett they're going to describe the patient that's maybe reaching up to the
shelf and experiencing pain, brushing their hair and having pain things like that,
definitely look out for. The location of the pain is usually going to be
over their lateral deltoid, so the anterior lateral portion of the shoulder. And
then they also may describe pain at night, so complaining like when the patient's
lying on the shoulder at night, they're experiencing pain. That's the classic presentation.
Will look out for in vignettes the pain over their lateral deltoid when they're
reaching overhead, or complaining of pain at night and real life, though it's
possible that they may just develop weakness decreased range of motion. Other studies even
suggest a large portion of rotator cuff tears. They're actually asymptomatic. But for
the exam pain with overact, pain with overhead activities, pain at night done
physical exam. So there's a lot of special maneuvers for the rotator cuff when
you're looking for impingement and tears. So three that I feel you should be
familiar with at seem to be tested on the most is the Hawkins test,
the near tests, and the empty Can test. Again, these are for
both impingement and tears. So let's start with the Hawkin and the Near test.
These are both really good tests to test to assess for impingement. So
the Hawkins test, also known as the Hawkins Kennedy impingement test, the patient's
going to have their shoulders stabilize and positioned in ninety degrees of elevation. The
elbow is going to be bent to ninety degrees. The examiner is going to
place internal force on the patient's shoulder, and then any reproduction of pain elicited
by the internal rotation would be a positive test for impingement. Again, if
you need visuals on any of these, check out the YouTube channel. Have
a lot of different pictures and things like that that kind of help. So
the way that I used to remember this test, the Hawkins test, was
if you can visualize when you were a kid, did you ever call someone
a chicken? You do the little arm flapping thing like wings. That's exactly
what this looks like when you're doing the Hawkins test. Their shoulders up,
their elbows bent. So when I see Hawkins test, it makes me think
of a hawk flapping its wings. And I'll help you remember this is the
one where it looks like you're flapping your wings like a bird or a hawk,
with the elbow bent, shoulder elevator elevated, and the examiner applying internal
rotation. That's exactly what this looks like. You'll have to take my word
for it or check out some pictures of the Hawkins test, but it looks
like somebody like flapping their wings like a hawk. So again remember that in
your os keys and things like that, you'll remember what the Hawkins test looks
like and what it involves. So remember Hawkins tests flapping your wing like a
hawk. I let's talk about the near test. So the near test,
the shoulder is going to be forcibly flexed and internally rotated. So one hand
is going to be placed on the shoulder and the scapular area to keep the
shoulder from shrugging. The other hand is going to passively lift the arm all
the way up to the ear. The arm is going to be internally rotated
with the thumb facing down, and then any reproduction of pain is a positive
test for impingement. May see some variations of this test with the arm and
neutral position rather than internal, but most of the time it's going to have
internal rotation. Ice Remember near is by the ear because and this test,
your arm goes all the way up and the shoulder winds up right next to
the ear. So when you see the near test, remember near is the
one by the ear. And then finally, the empty can test, also
known as the Job's test. This is a good test to evaluate superspinatus function.
Sometimes it's considered the gold standard test due to how well it isolates the
superspinatus in the way that the arm is position to really isolates it well.
So the patient's going to place a straight arm out at about ninety degrees of
ab duction and thirty degrees of forward flection, then internally rotating the arm completely.
The thumb is going to be pointing down. And then the patient then
resists. The clinicians attempts to depress the arm, so you're trying to push
it down. They're resisting. So again the patient raises their arm forward,
elbow extended, thumbs down as if emptying a can. Examiner's going to apply
pressure to the top of the arm, pushing it down. The patient attempts
to resist. This. Pain without weakness is going to suggest tendinopathy. Pain
with weakness is consistent with the tendon tear There's a lot of other tests,
but in my experience, those are the three that seem to be most often
tested on, so definitely be familiar with those three. Now, treatment conservative
versus surgical repair, there's nothing really specific to know here. Treatment is all
going to depend on. It's really a several factors like the duration of the
symptoms, the type of tear partial versus full thickness, patient age, activity
level, etc. That's going to guide the treatment as to whether or not
they're going to need surgical repair or if they're better suited for say physical therapy.
Now, if we're talking about tendonitis and the impingement of the rotator cuff,
treatment is primarily going to be physical therapy and sets, etc. You're
gonna find with most of MSK treatment is pretty repetitive. It's not very high
yield. That's why I kind of run through them quickly because there's just not
much to know from an exam standpoint, So from breezing over and I'm skipping
in some cases, it's just because there's nothing really for you to memorize.
If there's something high yield for treatment, I'll definitely make sure to bring it
to your attention, all right, so let's move on another area of the
shoulder known as adhesive capsulitis, also known as a frozen shoulder. So this
is a painful and stiff glenohumeral joint that has lost its distensibility and range of
motion. So it's exactly what it sounds like. It's a frozen shoulder.
It's hard to move. Passive and active range of motion are going to be
substantially reduced. Risk factors diabetes, this is a big one. Remember that
frozen shoulder is very common in diabetics, and the vignette it will very very
likely be a diabetic patient. There's actually a study that showed the incidence of
frozen shoulder and patients with long standing type one diabetes had a lifetime prevalence of
up to seventy six percent. So diabetic patients remember that the other risk factor
to know is thyroid disorders, particularly hypothyroidism, may increase the risk for frozen
shoulder as much as two point seven times. And then there's some other causes
that you shouldn't memorize should not memorize, like dyslipidemia, prolonged immobilization, stroke,
auto immune disease. Secondary problem after shoulder injury. Focus on diabetes,
they got that sticky shoulder from all that extra sugar and thyroid disorders. And
then also know that this is very common in women, particularly in the fifth
and sixth decades of life. It's actually really rare to see the impatience under
forty. So in the vignette, be looking for a female in their fifties
or sixties with diabetes or thyroid disorder. For diagnosis, There's nothing I really
know here. Frozen shoulder is very much a clinical diagnosis made on the basis
of the medical history. The physical exam imaging really has very little value except
just to rule out your differentials like osteoarthritis and things like that. Treatment is
also pretty low yield most cases. Frozen shoulders is self limited condition. Physical
therapy is the most commonly employed treatment option. Google corticoid injections and SAIDs other
supportive measures, but nothing really to commit to memory here, all right,
So moving on down the arm. Supercondular humorous fractures, so supercondular fractures of
the distal humorous You're going to see this most common in children two to seven
years old, so most frequently in children two to seven years old. So
be looking for a child in the vignette. Supercondular fractures are actually the most
common mediatric elbow fracture as far as the mechanism of injury. Foosh with the
elbow extended. So foosh foosh with the elbow hyper extended. So you're gonna
hear me saying that a lot. So extension fractures are actually going to account
for approximately ninety five percent of all supercondular fractures, and this is typically going
to be from a foosh mechanism. So foosh stands for fall on outstretched hand
and then in this case, the elbow is going to be hyper extended.
Like we talked about before, this is really seen very commonly in children,
and the reason is because children have this increased flexibility in their joints, They
have this ligamentous laxity, and when they fall with their arm extended out,
they're more susceptible to hyper extending the arm when they fall, and then hyper
extension is what generally leads to this type of fracture, to a supercondular fracture.
So remember supercondular foosh with hyper extension diagnosis, you're going to get an
X ray and once you're looking for here is fat pad. So the only
thing I really think you should be aware of, at least for imaging when
comes to supercondular fractures for the exam are fat pads. So in a non
displaced or minimally displaced fracture of this region, sometimes you actually can't see the
fracture. Sometimes it can't be visualized. And the only indication that a fracture
is present is an elbow effusion like seen in an anterior sale or posterior fat
pads signs. So let's talk about fat pads for a second. In the
elbow, you have fat pads. Usually they're not visible on X ray.
I'm going to talk about this a little bit more when we get to radio
head fractures. Next your interior verus posterior which you can be normal, which
you cannot. But generally fat pads, particularly posterior fat pads, they're not
visible unless you have an acute injury and then this blood starts to collect.
This hemarthrosis elevates the fat pads out of the coronoid and the electronoid electro non
fossa, and that's what makes them visible on radiographs and actually in more than
ninety percent of cases where imaging shows posterior fat pad displacement, a fracture is
seen on initial or follow up radiographs. So at the elbow will be looking
for your fat pads and then also be aware there is something called an interior
humeral line. If there's any displacement of this line, this can also indicate
a displaced fracture. I don't think they're going to ask you about this though,
Just really focus on your fat pads now. Complications. There's a lot
of complications that can arise from a supercondular fracture, vascular insufficiency, nerve injury,
compartment syndrome, So I want to make sure you're doing a complete neurovascular
evail in these patients. You need to check the sensory and the motor function
of the medial, of the median, radio owner nerves. You want to
assess the radio and brakual pulses. What you really need to be looking out
for. An exam question when it comes to complications of a supercondular fracture is
something called Volkman's schemic contracture. So this isn't common, but it's definitely tested
on. So when you have this type of fracture and you have a vascular
injury and swelling. This can potentially lead to compartment syndrome, and if that
compartment syndrome isn't treated in a timely manner, the associated a schemia and infraction
can lead to Volkman's a schemic contraction. So what this causes is you have
this fixed flection of the elbow, the extension of the MCP joints. But
it really simply it's this claw like deformity of the hands fingers and the risk
risk. So for the exam, if you see Volkman's contracture right away,
be thinking of a supercondular fracture, because while this can be seen with other
types of injuries of the arm, it's most commonly seen with supercondular fractures.
So associate those two in your head Volkman's supercondular, supercondular Volkman's or just remember
what I did and remember my vocal at my Volkswagens in super condition, so
Volkswagen helps remember Volksman contracture. Supercondition helps remember supercondular fracture. So my Volkswagen's
in supercondition Volkswagen Volkman's contracture supercondition helps you remember supercondular fracture. All right,
so treatment is going to be splint verse surgical most displaced or minimally displaced fractures,
you're going to apply a posterior your splint and sling. Displaced fractures generally
be repaired surgically closed versus open reduction with percutaneous pin play. Nothing really to
memorize here. So for supercondular fractures, remember this is very likely going to
be a young child in the vignette. It's going to be a foosh injury
with hyper extension. You remember fall on outstretched hand, Look for your fat
pads on X ray, and then finally remember your Volksman's contracture for potential complications.
Remember by Volkswagens in supercondition. Okay, so next radiohead fractures. There's
really just a few things to know here. The mechanism of injury is going
to be another foosh, So another foushure like in supercondular humeral fractures and many
other fractures of the arm. Really, so falling onto an outstretched hand is
the most common mechanism for radiohead or neck fractures. Because this type of injury
there's this sudden impaction on the radius and onto the capitulum. So as far
as diagnosis, you're going to get your X ray. You're looking for fat
pads here again. Now, the fat pads in radiohead fractures are even more
important than supercondular fractures that we just discussed before, because non displaced radiohead fractures
can very very often be missed and an elevated interior and posterior fat pads maybe
the only sign of an occult radiohead fracture. So be looking for those fat
pads in the vignette and in real life. Wanted to give you a little
bit of extra knowledge while we're on the topic of fat pads, so I
interior fat pads can actually be a normal variant, particularly in children. While
a posterior fat pad should really never be visible. It'll almost always indicate trauma.
So again, remember anterior fat pads can sometimes be a normal finding,
while posterior will almost always indicate a fusion caused by trauma. And I used
to remember and tieror fat pads and tior with an A can be AOKA,
and posterior fat pads with a P are always problematic. So anterior AOKA posterior
problematic helps you remember which one can be normal, which one is always bad.
Treatment is going to be splint for a surgical nothing really to know here.
Depending on the severity of the fracture and mobilization with a sling or posterior
splint may be sufficient for surgical repair for your displaced For more severe fractures,
again, little mill for radiohead fractures, just remember your food injury. You
know your fat pad sign for those occult fractures. Occult fractures. If I
didn't mention this before, it just means a hidden fracture that's not visible on
imaging. Let's move on to ulner shaft or night stick fractures. Really,
very little to know for this one. I only bring it up for some
reason. This does come up on exams. Main takeaway here is to know
the type of injury that's related to the specific fracture. So this is going
to be an isolated ulner shaft fracture. The mechanism of injury is going to
be a direct blow to the forearm. So these types of fractures almost always
result from a direct blow to the forum. So this happens when the patient
was using the forum to protect their head from their torso, like from a
blow with a night stick or a pool stick or something like that. So
if you're familiar with the mechanism of injury, when you see it in a
vignette, you'll know you'll be looking for an ulner fracture. In the answers,
treatment is going to be non operative treatment verse surgical repair. So casting
splinting is the accepted approach for uncomplicated night sticks fractures. But if the fracture
is comminuted over fifty percent displacement, these types of fractures are suited for better
suited for surgical repair. Okay, Montezia and Galiazzi fractures. So with Montezia
and Galiazzi fracture is the only thing I feel you really need to remember that's
normally tested on is what bonus fracture and dislocated in each. The rest of
the stuff's pretty low yield that you need to know. So Montezia is going
to be a proximal ulnar fracture accompanied by a radial head dislocation. So again
Montesia proximal ulnar fracture companied by a radial head dislocation. Galiazzi is going to
be a radial midshaft fracture associated with a dislocation of the distal radial ulnar joint.
So both of these are not just fractures, but they're also dislocations,
and you need both to meet the criteria for either a Montezia or a Galiazzi
fracture, you need to have both a fracture and the dislocation. Diagnosis is
going to be done with an X ray. Treatment is going to be surgical
repair. Generally, in both of Montezia and a Galiazzi fracture, treatment is
almost always going to be surgical. Montega fractures in particularly are almost in particular,
almost always unstable and always require surgical treatment. Most of the time this
is going to be with an RIF open reduction internal fixation. So again the
highest yield thing is remembering which fracture and dislocation is of what bone in each
condition. So the way that you remember that is by remembering gruesome murder.
So gruesome murder helps to remember which bonus fracture and then secondly which is dislocated,
So remember gruesome murder. So for Montigia and Galiazzi fracture, so gruesome
The first three letters in gruesome are gru, so the G stands for Galiazzi,
the R stands for radius fracture, and then the U stands for owner
dislocation. So that's in gruesome Galiazzi our radius fracture, and then the U
stands for owlnar dislocation. I know, technically I said this is a dislocation
or instability of the radio owner joint, not specifically in older dislocation, but
in most cases, what we actually see is this dorsally displaced owner head,
which will be very evident on X ray, so you'll see the owner hopped
out of place. So remember gruesome gru Galiazzi, radius fracture, owner dislocation,
and then murder the second part of the sentence. The first three letters
are Mu, R, and that stands for M stands for Montezia, U
stands for ulnar fracture, and then the R stands for radial head dislocation.
So again remember gruesome murder. First three letters of gruesome, Galiazzi, radius
fracture, owner dislocation, first three letters of murder. Help you remember Montezia,
ulner fracture and radio head dislocation. Okay, radial head subluxation This is
also known as a nursemaide elbow. It's important to know this because not only
may it come up on an exam, but if you wind up working anywhere
with pediatric patients, you're going to see this very frequently. So what happens
here you have the movement of the head of the radius that slips under the
annular ligament. So we talked about this before, but the ligaments and children
are much more lax and weak. So in a child, when you have
this sudden pulling on the arm, pulling on the distill radius, the annular
ligament, which is a band of fibers that encircles the head of the radius,
it slips right over the head the radius, and then this slides into
the radio humeral joint where it becomes trapped and these children start to have pain.
It's most common in one to four years of age, so common between
the ages of one to four years. Eighty percent of cases are actually going
to fall within the one to three year range. So if it's not a
young child in the vignette, it's not a nursemaid elbow. This is a
one hundred percent going to be a young child. The reason we see this
more frequently in young children not adults. Is because the attachment of the annular
ligament is much weaker and children than adults. As the child grows, the
attachment between the annular ligament and the radius becomes thicker and stronger, and it
prevents the subluxcation. Usually by the age of five years, the ligament is
going to be strong enough and thick enough that it's highly unlikely to tear to
become displaced. So generally you're looking for a child one to four years.
I'm not saying it's impossible to see this like in a seven or eight year
old, but probably not very common at all. Look for a very young
child. In the vignette mechanism of injury, this is going to be a
polling injury. So the classic mechanism for a radiohead subluxation is going to be
consisting of a pull injury. So, for instance, a parent grabs the
arm of the child to prevent them from falling, maybe the child's being swung
by the forearms or during play with their siblings or parents. You're looking for
some type of pull or tug on the arm. And even yet, the
reason why this is actually called a nursemaid elbow was because back in the day,
when nursemaids as they were called back in the day, took care of
children, they were often blamed for causing this injury by tugging on the child's
arm. So look for that pulling or tugging of the arm. Diagnosis is
going to be clinical. So a majority of the time this is a clinical
diagnosis. They had a pulling or tugging type injury. They fit the age
range on physical exam, they don't have any bony tenderness, no deformity,
no swelling. Usually that's all you need to make the diagnosis. Imaging is
usually not necessary. Now treatment there's very few things in medicine where we can
fix someone's problems and a matter of seconds and make them feel completely back to
normal. But this is one of those few circumstances. So with treatment it's
going to be a close reduction, and there's a couple of ways to do
this. The technique preferred by up to date, which has a higher rate
of success, is reduction with hyperpronation rather than the other alternative, which is
this supernation flection method. So the way you do the hyperpronation method is going
to be you hold the child's arm at the elbow. You place pressure with
a finger on the radio head and then the other hand holds the discal forum
and you hyper pronate the forum, so you turn the arm all the way
over and in a lot of times you're going to feel this click or this
pop over the radial head. But it reduces and then these kids within minutes
are going to be back to normal and playing and smiling in most cases,
at least from my experience. So for radial head subluxation, main takeaways here
looking for a child under five looking for a pulling injury. It's a clinical
diagnosis and treatment is going to be with a closed reduction, very straightforward.
All right, Medio versus lateral epicond litis. These are really simple, there's
very little to know. But the reiblement is you can easily get them mixed
up and miss out on an easy exam question. So let's go over what
you need to know the little differences between the two and in the monic to
remember them. So, lateral epicondolitus, which is also known as tennis elbow,
it's a frequent complaint of tennis players, actually up to fifty percent of
tennis players. It's mostly due to poor technique. So it's an overuse injury
of the origin of the common extensor tendon which leads to tendinosis and inflammation of
the extensor carpi radialis brevis precipitated by repetitive wrist extension. And the reason why
you have painted the lateral epicondyle is because the lateral epicondo of the elbow is
the bony origin for the wrist extensors. So who are you looking out for?
This is going to be of course tennis players. Like I said before,
tennis is the most common sport to cause lateral epicondolitus. It can be
seen in other sports squash, badminton, as well as certain occupations like carpenters,
bricklayers, seamstresses. But for the sake of the exam, be looking
for your tennis player, and on exam you're going to be looking for localized
tenderness over the lateral epicondyle and pain with resisted wrist extension. So lateral epicondo
lightis associated with extensive extension and extensor so pain with risk extension. On physical
exam, overuse of the extensor tendon, the extensor carpi radialist brevis precipitated from
repetitive risk extension. Remember what I keep saying, extension extensor, lateral epikind
of lightis. Remember extension extension extension That's how they're going to get you on
an exam question if you don't remember this and you get it mixed up with
medial epicind of lightis, which is the opposite involving flexion rather than extension treatment.
It's going to be conservative and SAIDs activity modification, steroid injections, counter
force braces, not anything really important to know here. Medial epicondo lightis.
So this is also known as golfer's elbow. It is an overuse injury involving
the proximal tenders of the pronator, terrace and flex or carpi. Radialists probably
mispronouncing all of these overt imachin I am. It's primarily due to repetitive forceful
forearm pronation and risk flection. So this is the opposite and lateral we were
talking all about extension extens or tendence down medial It's all about the flection flex
or carpon radialis caused by repetitive risk flection and just like we talked about before
in lateral epicondolitis, the reason why you have pain in the medial epicondo in
this case is because the medial epicondyle is the common origin of the forearm flexor
and and the pronator muscles. So in the vignette you're probably going to get
a golfer medial epicondolitis, as we know is called golfer's elbow. But interestingly
enough, around ninety percent of cases are actually non sports related, in particular
occupational settings with repeated forceful gripping during heavy labor like plumbers, carpenters, construction
workers. But for the exam, I probably remember and focus on your golfers
on physical exam. They're going to have localized tenderness over the medial epicondyle and
pain with resisted wrist flection, so flection flection, flection treatment is going to
be the same as in lateral conservative and SAIDs activity modifications, steroid injections,
counterforce braces. Nothing to memorize there, all right, So the main thing
to remember for both later epicondolitis remember tennis players pain with wrist extension against resistance
problem with the extensor tendence caused by repetitive risk extension, Lateral should equal extension
in your mind. Now, medial epicondolitis golfers pain with risk flection against resistance
problem with the flex or muscles caused by repetitive wrist flection. Medial should equal
flection in your mind. If you can remember one by method of exclusion,
you can remember the other. And here's how you're going to do that.
So with medial epicondolitis aka golfer's elbow, I want you to remember mini golf
is fun. The M and mini helps you remember this is medial epicondel involved
in golfer's elbow golf obviously because this is also known as golfer's elbow. And
then the F and fun helps you remember this involves flexion, whether it's pain
with risk, flection against resistance on exam or the fact that the flex or
carpyrradialis or that it's caused from repetitive flection. Mini golf is fun. Mini
stands for media up a condal golfer golfer's elbow, and F and fun for
reflection flexor. And then you know ladder up condolitis is the opposite problems with
extension not flection. So remember mini golf is fun on your exam. When
you get a question on one of these, because you're very you very likely
will. And honestly, I had so much trouble remembering which was which until
I came up with anemonic, and now I never forget. So remember mini
golf is fun. Okay. Next, I wanted to talk about two conditions
that are also really easy to get mixed up on an exam, and they
can have similar presentations, and then I'll teach you some ways to help differentiate.
So that's going to be cubital tunnel syndrome and carpal tunnel syndrome. So
let's start with cubital tunnel syndrome, which is ulnar neuropathy. It's a compressive
neuropathy of the ulnar nerve caused by compression in the medial elbow. Clinical manifestations,
this is the highest yield thing to know right here. So paristhesia of
the fifth finger and half of the fourth so numbness tingling in the older nerve
distribution. That's going to be your most common initial complaints. So paristesia is
the small finger and older half of the ring finger. It's also possible to
have radiating pain down from the elbow. Usually you're looking for paristesis and the
little finger and half of the ring finger. That's the key to remember here.
So you're going to get a question, the patient's gonna have some tingling
in their hand. The answer choices, they're going to have both cubital tunnel
syndrome and carpal tunnel. You need to remember which has which nerve distribution,
and this is the way that you remember it. So cubital tunnel starts at
the little finger, the pinky and half of the ring finger. Carpal tunnel
starts at the big finger, the opposite end the thumb or the first digit,
all the way through the other half of the ring finger. So how
do you remember that for the exam, Well, cubital starts with the letters
sub sub cub and as we know, cubs are little bears, bear cubs.
And then help to remember that cubital cub is the one that starts at
the little finger, the pinky, and by method of exclusion, you crewmember,
carpal tunnel started at the other end, the big finger, the thumb.
So as soon as you see cubital tunnels syndrome. Think of a cub,
cub a little bear. Remember this is the one that starts at the
little finger. Carpal tunnel starts at the other hand, at the big finger,
the thumb. So I remember for the exam, and I got the
question right because I remember cubs or little animals. Cubical tunnel syndrome starts at
the little finger. So on physical exam, there's a few different provocation tests
for cubital tunnel, but the one physical test I'd remember for this is the
Tannell sign, as this is the one you'll hear most often, or the
Tennel test. So this is just percussion or tapping over the ular nerve and
the umlar groove of the elbow at the cubital tunnel. So when you do
this, if they have parastesia and the fourth and the fifth finger, that's
a positive Tennell sign. There's also a Tannel sign or test and carpal tunnel
as well, so don't get them mixed up. We'll go over that.
Next treatment for cubital tunnel is going to be conservative for a surgical Initially,
start with activity modification. If this is from some sort of repetitive trauma or
occupational cause. You can use splints and SAIDs. Surgery is really only going
to be for severe or progressive symptoms. Now let's talk about carpal tunnel syndrome.
So this is compression of the media nerve as it travels through the carpal
tunnel. So cubital tunnel syndrome was ulder nerve compression. Carpal tunnel is media
nerve compression. Different nerves affected, different nerve distribution, and different area affected.
So again this is the really important thing you need to remember to differentiate
the two. So in carpal tunnel syndrome, you're going to have pain and
parasthesia of the first three digits and half of the fourth. So a lot
of times the pain is going to be present at night. It's going to
wake them from sleep, the hallmark presentation paint or parasthesia, and the distribution
that includes the media nerve territory, so thumb, the first digit all the
way through the fourth digit, the radial or lateral half, so first,
second, and third and half of the fourth fingers different than cubital tunnel,
which we know started at the opposite end of the hand at the little finger,
fifth digit and half of the other half of the fourth digit on the
ulner side, so carpal tunnel fingers one, two, three and a half
of four, cubital tunnel finger five and half of four. Other things to
look out for, although not as important. They may have weakness or clumsiness
when using their hands. They may have difficulty holding objects, turning keys or
door knobs, buttoning clothing. They may have atrophy of the theen or eminence
in advanced cases. So those are just some other things to be aware of
now. Risk factors. There's a lot of risk factors for carpal tunnel obviously
repetitive hand and risk use, particularly with some occupations authritis, obesity, female
gender, but the ones that I would focus on for the exam are pregnancy.
Third trimester is usually where the symptoms will start to manifest. It can
be diagnosed earlier on than this though diabetes molitis. Both type one and type
two diabetes can be associated with carpal tunnel syndrome and then hypothyroidism. So hypothyroidism
contributes to the development of carpal tunnel by increasing peripheral tissue aedema. So those
are usually the ones you're going to get tested on. Let's talk about one
other high yield area for carpal tunnel that you'll definitely need to know for your
OSCIS. That's your physical exam tests. So there's a few revocative maneuvers you'll
hear about for carpal tunnel. The two that you need to know, the
one that frequently come up are the Tannelle test and the Phalin test. So
Tannell test just like in cubital tunnel, or we tapped on the cubital tunnel,
now we're tapping or percussing over the carpal tunnel. It's easy to get
these physical exam tests mix up. So I used to remember the t and
Tannell stood for tapping because it helps you remember the test is performed. So
you're tapping, tapping, tapping on the median nerve over the carpal tunnel.
Positive test is defined as pain or parasthesia of the median innervated fingers, remember
first finger through half of the fourth and then we have the Phalin test.
So the Phalin test is performed by having the patients bring the dorsal surfaces so
the back of the hands against each other, pushing them up against each other
at the top of the hands push them together and this provides hyperflection of the
risks while the elbows are going to remain flexed. You do this for one
minute straight and a positive test is going to be pain or parastesia again and
the media innervated fingers. The way that I used to remember this is if
you actually look at a picture of the phalin test. When you flop your
hands down like this, it looks like your hands have just kind of like
flopped over. They've fallen over. So when I see phalin tests, I
just remember that your hands have phalin over. Because the hands are flopped over,
they look like they've fallen or phalin over. So I just remember phalin.
Your hands have phalin or fallen over. Tannell. Remember t for tannel
and tapping tapping on the media nerve phalin. Hands have phalin over pressed up
against each other for a minute. So those are the two provocation tests i'd
know for a carpal tunnel. Also be aware there are nerve conduction studies,
electromiography. Those are some other diagnostic tests can help you with the diagnosis,
but focus on those physical exam tests. I talk about the tannel and the
phalin treatment. Conservative or surgical so splinting glucocorticoids, whether it's PO or VA
injections are going to be useful for symptom relief, and up to two thirds
of patients with mild or monitor carpal tunnel severe refractory cases, of course,
surgical decompression may be needed. Let's move on to our scafloid or our navicular
fracture. This is your most common carpal fracture. So scaffoid fractures are the
most common carpon bone fracture. They're seen in around sixty to seventy percent of
all carbal fractures, so that's an important one to know. That's often tested
on mechanism. Another foocher so foosh fallen an outstretched hand will likely be the
cause of a scafoid fracture, or really any other injury that involves an axial
load placed on the wrist. On physical exam, they're obviously gonna have some
pain in the wrist, But where is the pain going to be. It
gonna be a few different places. It can be distal to the listers,
tubercle, the volar prominence. But the only one that you have to know,
the one that will ninety nine percent be how it's described in the vignette,
will be pain or tenderness at the anatomic snuffbox. Know this for the
exam. As soon as you hear anatomic snuffbox tenderness, be thinking scaffoid fracture
always, so any tenderness in the snuffbox should be treated as a scaffoid fracture
until proven otherwise. The snuffbox is located just proximal to the base of the
thumb. Now diagnosis, you're gonna order a risk X ray. Obviously you
want to include a scaffoid view. The thing about scaffoid fractures, though,
is that they can be missed on X ray. Is pretty often X rays
taken soon after the injury can be missed up to fifty four percent of cases,
so half the time. So if the history and physical exam findings are
suspicious for a scaffoid fracture but the X rays are negative, you're often gonna
have to send these patients for a CTRMRI because if you miss a scaffoid fracture,
the scaffoid, unfortunately has a crappy blood supply. And can be at
risk for non union osteon necrosis. So if it fits the picture of a
scaffoid fracture but the X rays are negative, you still treat it like a
fracture until you can definitively say otherwise. Treatment thumb spike up. Treatment for
majority of patients with a non displaced fracture or those patients who have negative X
rays but have snuffbox tenderness, you give these patients a thumb spike until you
can roll out a fracture with the scaffoid. Again, treat it like a
fracture until you know it ain't surgery. If it's a displaced fracture or there's
neurovascular compromise, surgical repair will be appropriate, but in most cases it's going
to be your thumb spike of splint will be the answer. Choice. All
right, let's talk about distal radius fractures are Colleagues versus our Smith fractures.
There's really just a few things to know here, mainly just being able to
differentiate between a Collie and a Smith fracture mechanism. Again, Foush, most
common mechanism of the distal radius fracture is going to be falling on an outstretched
hand. More of the more often the risk is going to be extended in
a Collie fracture injury, and often you'll see it's flexed in a Smith fracture.
So just a little side note there on physical exam, collies fractures have
what's known as a dinner fork deformity, and this is due to the dorsal
displacement of the distal fragment. Collige type fractures are often said to have this
dinner fork appearance. If you want to see some pictures that have it in
the YouTube video. And then Smith fractures are sometimes described as a garden spade
deformity. Don't go too crazy memorizing these names dinner fork, garden spade,
because they're likely not going to use these buzzwords. You just need to remember
that one has dorsals displacement, the other has eventual displacement. I'm going to
give you anemonic for that in a second, but remember, I guess Smith
fracture sometimes known as a garden spade deform me, and that's if you see
like a spade or a shovel and has this little bump on it, and
that's because of the eventual displacement. It looks like that anyways. Diagnosis,
this is what you really need to know. So when you take an X
ray on a Collie's fracture, you're going to see dorsal displacement of the distal
radius fracture, dorsal displacement of the disarradius fracture, and a Collie's fracture and
a Smith fracture, you're going to see volar or palm our displacement of the
distal radius fracture. So remember Collie's dorsal displacement Smith volar or palm our displacement
of the distal radius fracture. That's the highest heal thing to know because this
was differentiates the two and it may be the only difference in the vignette.
So remember Collie's fractured, dorsal angulation of the radius, Smith fracture of volar
angulation of the radius. The way that you remember that a Collie's fracture is
dorsal displacement is because a Collie is actually a breed of a dog. Nice
and conveniently it's the same dog that Lassie was on that show a number of
years ago. So a Collie dog when you think of a Collie fracture,
Think of a Collie dog and the first two letters in dog are the first
two letters in dorsaldo. So this helps you remember Collie's fractures are doo dorsally
dorsally alculated radial fractures and by method of exclusion, smith is the opposite volar
angulated radial fractures. So when you see collie fracture, think of a Collie
dog doo dorsal dog treatment splint splint, reduction for surgery. So some fractures
can be treated with closed reduction sugar tongue splint. Other fractures are gonna require
surgical or repair defend, depending on the severity. Remember your Collie dog dorsal
angulation for your Collie fracture. Just knowing that one thing may get you the
question. Very likely it will if you ever forget which side is the dorsal
side of the hand or the risk. Remember the dorsal fin of a dolphin
is on its back. Therefore, a fracture with dorsal angulation will be angulated
for the back or the top of the wrist area. All right, lunate
fractures. So, lunate fractures are pretty uncommon. Their only account for about
four percent of all carpal bone injuries, but they do have some pretty serious
applications if they're not treated. So mechanism of injury is going to be another
fall on an extended wrist or any other type of risk hyper extension injuries.
These are going to be your most common mechanisms of injuries for a lunar fracture
diagnosis, so X ray. Main thing to know about X rays of the
lunate is that they're missed quite often with playing radiographs. If there's any clinical
suspicion, it's important to obtain vanced imaging like ctrmri CT is going to be
preferred. One of the thing that I wanted to mention because it may come
up if you have a dislocation of the lunate bone. The lunate gets displaced
and angled in this volar direction and in comparison to the surrounding structure is the
distal radius metacarpals which are all in normal alignment. It looks like a tea
cup spilling over on lateral X rays, at least that's what they say,
and it's called a spilled tea cup sign. So just in case, you
hear that being mentioned at any point you'll know. This is what can be
seen in a lunate dislocation. So you need to know a complication a vascular
necrosis and kind box disease. So aggressive collapse of the lunate mechanism of injury
is really unclear. This is kind box disease, so it's a progressive collapse
of the lunate mechanism of mechanism is really unclear. It evolves to appear some
disruption of the blood supply. It's likely related to undiagnosed fractures of the lunate.
Some other complications with lunar fractures are complex regional pain, syndrome, osteoarthritis.
Nothing specific I would know for the treatment for lunar fractures, except in
the case of a dislocation, in which immediate reduction is really important to prevent
a number of complications. So again that's your lunate fractures and a little bit
about dislocations. Not a lot to know there. Let's talk about decoreving tendinopathy
next. So this is a thickening of the abductor policis longest the apl and
extensor policis brievious, the EPV tendons and the tunnel or the sheath and the
first extensor compartment. So the abductor policis longest apl the extensor policies brievious EPB
tends. They pass through this tunnel called the fibro osseous tunnel from the forearm
into the hand, and any thickening of these tendons passing through here, or
thickening of the tunnel itself can restrain the gliding motion through the sheath, which
can lead to the clinical manifestations will go over. So think of a rope
going through a little hole and the rope's getting bigger or the holes getting smaller.
Eventually it's going to get stuck. I don't recommend memorizing abductor polysis longest
an extensor polysis brevist. Those are hard enough to say. It's just too
much brainpower to memorize those complicated names. What I would recommend memorizing, though,
is apples with extra peanut butter are delicious, because if you can remember
that apples spelled apl apl as an APL tendon with extra peanut butter EPB as
an EPB tendon are delicious as in decore vein tendinopathy. If you can remember
that, that helps you remember your APL tendon and your EPB tendon are going
to be involved in this decorvein sendingpathy, and this should be enough for you
to be able to pick them out on the multiple choice question by remembering the
letters involved in the full name. So if you can remember abductor policies as
long as an extensor policies breathes, in addition of the twenty thousand other things
you need to for PA school, more power to you. But I just
remember apples with extra peanut butter are delicious. That was enough for me to
help pick out the right answer on my clinical medicine exam. So apples again,
APL, extra peanut butter EPB are delicious. Decorva intentanopathy. You're done,
all right, So what about the patient demographic you're looking for? So
you are going to be looking for women between the ages of thirty to fifty
years of age, and then it's also prevalent in a subset of women in
the postpartum period. Symptoms usually going to present about four to six weeks after
delivery. There's a lot of theories why this happens in the postpartum period,
repetitive motion of the hands required to lift and hold newborns, hormonal causes for
fluid retention, whatever the case. In the vignette, you're looking for both
women in the thirty to fifty year age range and also postpartum women clinical menifs
stations, they're going to have pain at the radial side of the wrist.
It's going to be worse with thumb and wrist movement. So the tendons we
went over before, the EPB in the apple, the EPP in the apple,
the EPB and the APL are responsible for movement of the thumb, So
you can imagine a lot of the complaints are going to be related to thumb
movements, and so the EPB and the APL are responsible for movement of the
thumb. Diagnosis so decavent tendonopathy is based upon the history of an atraumatic radial
wrist pain and positive physical exam findings, So imaging like X ray is not
really necessary except to rule out other differentials which may have a similar presentation like
osteoarthritis. The main thing to know for diagnosis is a physical exam maneuver called
the Finkel steam test. So the Finkel steam provocation test involves the patient wrapping
their fingers around their thumb, clasping it in their palm, and then you
apply ulnar deviation to the wrist. If they have pain over the radio styloid
area so the basic of the thumb, this is considered a positive test.
Again, that's the Finkel Steing test. Treatment thumb spike a splints going to
be the big one and SAIDs google cordecoid injections. So decoving tendonopathy is generally
non progressive. It's typically self limited, so most of your conservative measures are
going to be your mainstay. Again, thumb spike a splint is commonly used,
and said steroid injection surgery really is going only to be for refractory cases.
Talk about mallet fingernecks. So this is a finger deformity caused by traumatic
disruption of the terminal slip of the extensor tendon at the distal interfalangeal joint,
so the dip joint. So you have some sort of trauma to the finger,
usually caused by a direct blow to the tip of the finger, so
maybe a ball striking the fingertip or the fingertip strikes a hard surface. The
trauma causes a tear in the extensor tendon at the dip joint. And this
is the tendon that allows you to extend your fingers so to hold them out
straight, and with this being torn, you can no longer do that,
so the finger remains in this constant slit state of flexion. Now on physical
exam, they're going to have an inability to extend the dip joint. This
is going to result in that flex DP So it's really simple. Patient's going
to have this constant flection of the dip joint. They're not going to be
able to extend the finger at that joint. This specific degree of the dip
angulation is often going to reflect the severity of the tendon disruption. Now diagnosis
X ray. So in some cases with the mallet finger, you're going to
visualize a bony evulsion of the distal failings at the site where the tendon attaches.
It just got ripped off during the injury. It's also possible just to
have just a ligamentous injury with normal bony anatomy, so you can see either
one. Now, treatment really important extension splinting of the dip joint for six
to eight weeks with twenty four hours of maintaining this extension, So the dip
joint must be maintained at full extension throughout the entire period, including during sleep.
If the joint extension is lost at any point during this initial treatment period,
the treatment clock is reset and an additional six weeks of splinting has to
be performed. So if you think about it, you're keeping those horn tendon
edges aligned. So as soon as you bend that finger just rips it tears
all over again. So the only wayfer it to completely heal is to have
that finger in full extension with the torn ligament aligned for six to eight weeks.
The majority of malletfingers are amendable to treatment with just splinting. Surgery is
really only going to be a reserved for large displaced fractures or other complex injuries
that may warrant with surgical referral. But really focus on splinting as that's going
to be your most common, your main state treatment. So maletfinger again,
extensor extensor tendon injury. Dip joint now flex all of the time. They
can't extend it, straighten it out with a splint done. That's your mallet
finger. Let's talk about ulnar collateral ligament injury aka a gamekeeper or skiers thumb.
It's an injury caused by damage to the ulnar collateral ligament of the thumb.
Mechanism of injury is going to be a forced abduction, abduction and hyper
extension of the thumb. This is going to be at the metacarpul philangial joint.
That's going to be your most common cause. So the thumb is stretched
and forced into extreme abduction, whether this is from a fall and athletic injury
skiing accidents where the thumb strikes a fixed ski pull, and that's where the
names skier stumb came from or the name gamekeeper stumb, so not so relevant
anymore. But basically this was this chronic degeneration of the owlner collateral ligament from
twisting the necks of too many birds and rabbits. So I'm making that up.
That's what gamekeeper stumb came from. So yeah, probably won't be the
reason why your patient comes in with this, but seventy plus years ago when
the name was created, it was today most often this is going to be
a skiing related injury or another athletic related injury. On physical exam, you
can pretty much confirm a UCL injury with your physical exam findings combined with your
appropriate clinical manifestations. So Valgus stress testing is going to reveal a loss of
integrity of the UCL, so the injured thumb will have increased laxity of the
MCP joints, so the thumb you're going to be able to pull much further
away compared with the uninjured thumb. When Valgus stress is applied, the test
is positive and the patient has the classic clinical manifestations paintings ascerbated by thumb extension
or abduction, and swelling along the owner aspect of the thumb at the MCP
joint. This is going to help to confirm the diagnosis, but you also
want to get an X ray of the thumb to rule out any possible bony
evulsion, fractures and definitive diagnosis can be made with an MRI or ultrasound,
but generally it's not necessary treatment. Thumb spike is splint so a mobilization with
the thumb spika will be sufficient in most patients. Some patients with a complete
tear or patients that don't respond to conservative therapy may require surgical intervention. Boxer's
fracture. This one's pretty much straightforward. It's a fracture of the fifth metacarpal
neck. Generally the fifth metacarpal neck fractures when we're talking about boxer fractures.
Occasionally sometimes we'll hear being referred to fractures of the fourth metacarpal as well.
But now it's common mechanism of injury direct trauma to a clenched fist. So
obviously the most common situation where you're gonna have direct trauma to a closed finch
or just say a clenched fist would be punching something, so that's going to
be the most common cause. So whether they're punching a wall, a solid
object, a face, that's why it's called a boxer's fracture. In reality,
though experienced boxers actually rarely sustained this type of fracture. It's more the
wild roundhouse punching motion that's common in street fights that cause this, Or someone
who punched a brick wall who's going to come in with this type of fracture,
rather than in a floyd Mayweather who's trained to punch the right way.
Diagnosis are going to be made with X ray so plaine radiographs of the hand.
This is going to establish the diagnosis of a metacarpal neck fracture and this
will also help to determine the degree of the fracture angulation. So treatment is
going to be with a mobilization with an gut or splint. So gut or
splint is going to be It's going to be used to mobilize fractures of both
the fourth and the fifth metacarpal necks. If the patient does have an open
fracture, a severely common unit fracture, or if they have significant angulation normally
over thirty to four where your degrees, this is going to require surgical consult
Otherwise, immobilize it with a splint. All right, let's finish up with
something a little bit different, and because I feel like I can no longer
talk, keep getting stumbling on my words, let's finish up with complex regional
pain syndrome. So this is an array of painful conditions that are characterized by
a continuing regional pain that is seemingly disproportionate in time or degree to the usual
course of any known trauma or other lesion. That's the official definition. So
basically, these patients have this prolonged pain. It's completely disproportionate to the initiating
event. Most frequently this is going to follow a bone or soft tissue injury.
So most cases there's going to be some sort of injury sprain, fracture,
et cetera. In some cases there may be no precipitating factor. It's
not common, and then weeks later they're going to start to develop this range
of clinical manifestations, autonomic dysfunction, pain out of proportion to the initial injury,
hair and nail changes. The path though, is really unknown, and
there's some proposed mechanisms, but definitely nothing to know for the exam. Now,
in clinical manifestations, this is the most important thing about complex regional pain
syndrome. It's the presentation. The diagnostic criteria is low yield, the treatments
low yield. It's all about being able to recognize the clinical manifestations. That's
what you need to know for the exam. So the main clinical manifestations of
complex regional pain syndrome are pain, sensory changes, motor impairments, autonomic syntoms
and trophic changes in the affected limb. This is usually going to occur four
to six weeks after the inciting event. The reason I'm covering this under the
upper extremity section for the pants is because this most commonly occurs in the upper
extremity around sixty percent of the time. So the way that I used to
remember the common clinical manifestations that you're going to see in a vignette for complex
regional pain syndrome is by remembering instead of complex regional pain syndrome, I want
you to remember complex regional paint syndrome. So PAI nt complex regional paint syndrome.
And what does paint stand for? So paint stands for the P stands
for perspiration, and this is due to the auto aconomic dysfunction, so forty
percent of patients are going to experience increased sweating on the side where they're experiencing
this. The A in paint stands for after injury, So after injury for
the A, because remember this is most commonly going to take place after some
sort of bone or soft tissue injury, So look for some sort of injury
mentioned in the vignette weeks prior the eye, and PAINT stands for inappropriate pain
because remember the pain experience is inappropriate, it's out of proportion to the initial
injury. Pain is typically the most prominent in debilitating symptom of complex regional pain
syntems. So remember I stands for inappropriate pain because it's not appropriate to have
ten out of ten pain in your risk from a sprain you had two months
ago, So remember inappropriate pain for I. The END stands for nail changes.
So remember I talked about before your trophic changes, so these patients may
have increased or decreased nail growth. Also look for hair growth changes as well,
but remember END stands for nail changes from your trophic changes. And then
the last letter T and paint stands for temperature changes. This relates back to
those autonomic changes. Again, these patients can have and some patients are going
to see a difference in skin temperature and the affected side versus the unaffected side
of over one degree celsius. So remember if you have a vignette you think
the patient they're talking about may have complex regional pain syndrome. Remember to look
for paint perspiration after injury and appropriate pain, nail changes, temperature, changes,
and that should be enough to get you there and get the right answer.
Now, diagnosis clinical features based on your H ANDP, So the diagnosis
is really just based upon the clinical features determined by your history and physical So
nothing really to know for the exam question. You're basically looking to see are
they having pain, sensory changes, motor symptoms, autonomic dysfunction? Are these
symptoms weeks out from an initial injury that would no longer be appropriate to persist
at this point in time. There are some imaging tests that can be used
three phase bone syntigraphy, radiographs, but there's nothing high yield, there's no
gold standard tests. Definitely nothing I would memorize for the exam, So just
know this is generally clinical diagnosis. Are the experiencing paint? If so?
Complex regional pain syndrome treatment it's multifaceted physical therapy and SAIDs tricyclic antidepressence, sympathetic
nerve blocks. Physical and occupational therapy are more or less considered first line treatment
for complex regional pain syndrome. But again it's a multifaceted, multi disciplinary approach.
There's not one specific thing to know for treatment. The main takeaway for
complex regional pain syndrome. To identify in a vignette is to remember the symptoms
that you're seeing in these patients. The treatments really not high yield. Diagnostic
criteria is really not that high yield. It's being able to recognize it in
a vignette. So remember complex regional paint syndrome, perspiration after injury, inappropriate
pain, nail changes, temperature changes. That's the main takeaway here, and
we are done with the upper extremity. Let's do five quick questions. Question
one, thirty two year old female presents the office complaining of pain at the
radial sign of her wrist that is most prominent upon movement of the thumb.
She has four weeks postpartum. Pasthematical history is otherwise unremarkable. On exam,
tenderness is noted over the radial styloid and pain. His experience with passive ulner
deviation of the wrist with the thumb flexed in the palm. What is the
likely diagnosis in this patient? So that is going to be decore vain tendinopathy.
So decarevyin tendonopathy we know is most commonly seen in women between the thirty
to fifty year age rage also common to see and postpartum women four to six
weeks after delivery. So she fits this criteria to the tea. Then she
states she has pained on the radio side of the wrist, and then a
physical exam tenderness over the radio styloid. She has a positive Finkelstein test for
the patient's wrist as put into Olnar deviation. All the patient's fingers are folded
over the thumb. This is a classic presentation for decorevain tendeonopathy. Question two.
A forty three year old female presents at the office complaining of numbness and
tingling in her hands, mostly affecting the thumb, index and middle finger,
and part of the ring finger. She states it is worse at nights,
sometimes awaking her from sleep. Both a Tannell and a Palin test are positive.
On physical exam. His patient is likely experiencing compression of which nerve,
so that is going to be the median nerve. So this patient is experiencing
carpal tunnel syndrome, which is compression of the medial nerve median nerves. So
we know this because the patient parastages in the median nerve. Territory, which
will be the first three fingers and radial half of the fourth. In addition,
she states it's worse at night, which is very common for carpal tunnel.
Finally, we have a positive Tannell and Phalin test that seals the deal.
We know this is carpal tunnel, which is median nerve compression. Question
three. Twenty seven year old Mail presents to the er after a bicycle accident
he had earlier on in the day. He states his bike hit a pothole
which sent him flying off his bike, landing onto his outstretched hands. He's
now complaining of pain along the radial side of the wrist and is tender just
proximal to the base of the thumb at the anatomic snuffbox fracture of which bone
should be suspected. And this patient until proven otherwise, so that is going
to be the scaffoid. This is a simple one scaffoid or avicular fracture.
You have a patient had to fall into an outstretched hand, which is often
the mechanism of injury for a scaffoid fracture, and he has pain on the
radial side of the wrist. Snuffbox tenderness. You are done. That is
a scaffoid fracture until proven Otherwise, as soon as you hear snuffbox, always
be thinking of a scaffoid fracture. Question four. Sixty seven year old Mail
presents to the office today complaining of persistent elbow pain. He does not recall
any trauma to the elbow, but the painting he is experiencing in his elbow
is affecting his golf game, as he is an avid golfer. On exam,
pain is elicited by performing risk flection against resistance. Tenderness would likely be
felt in which part of the elbow in this patient, so that would be
at the medial epicondyle. So you have a classic case of medial epicondolitis aka
golfer's elbow. If you have a sixty seven year old male avid golfer with
elbow pain, no preceding trauma, and then the key is that the pain
is reproduced on exam with the risk being flexed against resistance. So in this
case the patient wouldn't have pain and the medial epicondyle. And then of course
remember the demonic mini golf is fun and in mini helps you Remember this is
the media up a condal involved in golfer golfer's elbow golfs because this is known
as golfer's elbow. And then the f and fun helps you remember this is
going to involve flection, whether it's pain as pain with risk, flection against
resistance on exam the fact that it involves the flex or copper radialis or that
it's caused from repetitive flection. Mini golf is fun helps you remember all the
things that you need to know. And then by method of exclusion, you
know lateral epicond of lytis is the opposite problems with extension not flection. Last
question question five. Seventeen year old Mail presents to the er after sustaining an
injury to his right arm. After X rays are complete, the attending physician
assistant and forbs him that the X ray revealed a proximal owner fracture accompanied by
a radial head dislocation. This type of injury is also known as a and
that is going to be a Montegia fracture. So remember grew some murder Montegia
and Galiazzi fracture grew some first lead letters in russom stand for Galiazzi our stands
for radius fracture, U stands for owning dislocation aka the radio owner joint,
and then murder, which is the first three letters mu R montigia U stands
for owner fracture, and our stands for radiohead dislocation, which is the type
of injury we see here in this patient. All right, that is the
upper extremity for the MSK section for the pants. Thank you so much for
listening to the podcast, and good luck on you in paschool. Good luck
on your pants or pantry ears, and thank you again