WEBVTT 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