AnatomyAnatomyLecture 7Lecture 7

Upper ExtremitiesUpper ExtremitiesPhysician Assistant Physician Assistant

ProgramProgram

Miami Dade CollegeMiami Dade College

“ “I will persist until I I will persist until I succeed”.succeed”.

Og Og Mandino Mandino

ShoulderShoulder

ShoulderShoulder 1. Glenohumeral Joint: 1. Glenohumeral Joint: A spheroidal (ball & socket) joint A spheroidal (ball & socket) joint

that is the principal articulation of the shoulderthat is the principal articulation of the shoulder Inferior Glenohumeral ligamentInferior Glenohumeral ligament

A major anterior stabilizer of the glenohumeral joint, A major anterior stabilizer of the glenohumeral joint, especially with the arm abductedespecially with the arm abducted

Middle Glenohumeral ligamentMiddle Glenohumeral ligament Prevents anterior instability when the shoulder is Prevents anterior instability when the shoulder is

externally rotated and abducted 45 degreesexternally rotated and abducted 45 degrees Superior Glenohumeral ligamentSuperior Glenohumeral ligament

Works with the coracohumeral ligament to prevent Works with the coracohumeral ligament to prevent inferior instability in the adducted arminferior instability in the adducted arm

LabrumLabrum Is a fibrocartilagenous thickening surrounding the Is a fibrocartilagenous thickening surrounding the

glenoid that deepens the glenoid cavity. glenoid that deepens the glenoid cavity. It prevents abnormal motion and serves to anchor It prevents abnormal motion and serves to anchor

the inferior glenohumeral ligament complexthe inferior glenohumeral ligament complex

ShoulderShoulder 2. Sternoclavicular Joint: 2. Sternoclavicular Joint:

Gliding joint with discGliding joint with disc anchors shoulder girdle to chest wall anchors shoulder girdle to chest wall

(sternum to clavicle)(sternum to clavicle) 3. Acromioclavicular joint:3. Acromioclavicular joint:

Gliding joint with incomplete disc. Gliding joint with incomplete disc. Attaches acromion and clavicleAttaches acromion and clavicle

4. Scapulothoracic joint:4. Scapulothoracic joint: Medial border of scapula articulates with Medial border of scapula articulates with

posterior aspect of ribs 2-7posterior aspect of ribs 2-7 The ratio of glenohumeral to The ratio of glenohumeral to

scapulothoracic motion during shoulder scapulothoracic motion during shoulder abduction is 2:1abduction is 2:1

ShoulderShoulder 5. Supporting structures (from 5. Supporting structures (from

superficial to deep layers)superficial to deep layers) A. deltoid, pectoralis majorA. deltoid, pectoralis major B. clavicopectoral fascia, conjoined B. clavicopectoral fascia, conjoined

tendon, pectoralis minortendon, pectoralis minor C. subdeltoid bursa, rotator cuff C. subdeltoid bursa, rotator cuff

musclesmuscles D. glenohumeral capsule, D. glenohumeral capsule,

coracohumeral ligamentcoracohumeral ligament

FindingFinding SignificanceSignificance

Muscle wastingMuscle wasting Chronic rotator cuff tear, Chronic rotator cuff tear, nerve injurynerve injury

““Popeye” musclePopeye” muscle Proximal rupture of Proximal rupture of long head of bicepslong head of biceps

Scapular wingingScapular winging Serratus anterior (long Serratus anterior (long thoracic thoracic nerve) injurynerve) injury

Superior prominence Superior prominence Acromioclavicular Acromioclavicular (piano key sign)(piano key sign) separation/ clavical separation/ clavical

fracture fracture

Anterior prominenceAnterior prominence Glenohumeral dislocation, Glenohumeral dislocation, sternoclavicular sternoclavicular

injuryinjury

Systemic hyperlaxitySystemic hyperlaxity Multidirectional Multidirectional instabilityinstability

ExamExam Technique Technique SignificanceSignificance

Impingement sign passive forward flexion Impingement sign passive forward flexion pain = >90 pain = >90 degrees degrees impingement syndromeimpingement syndrome

Impingement Test same after subacromial relief of Impingement Test same after subacromial relief of pain= pain=

lidocaine lidocaine impingement impingement syndromesyndrome

Hawkins Test passive forward flex to pain= Hawkins Test passive forward flex to pain= impingement synd (Dump out can) 90 & internal impingement synd (Dump out can) 90 & internal rotation rotation

Apprehension Test Abduction to 90 & Apprehension Test Abduction to 90 & + appreh + appreh test= ant. test= ant.

external rotationexternal rotation shoulder shoulder instabilityinstability

Sulcus signSulcus sign downward traction sulcus below downward traction sulcus below on arm on arm

acromion=inferior laxityacromion=inferior laxity

ExamExam Technique Technique SignificanceSignificance

Crossed Chest,Crossed Chest, Passive forward flex pain= AC Passive forward flex pain= AC pathology pathology

Adduction testAdduction test to 90 & adductionto 90 & adduction

Acromioclavicular same after AC lido inj relief of Acromioclavicular same after AC lido inj relief of pain= AC path pain= AC path

InjectionInjection

Yergason testYergason test resisted supination pain= resisted supination pain= bicipital bicipital tendonitistendonitis

Lift off signLift off sign arm behind back lifted arm behind back lifted inability to inability to accomplishaccomplish

posteriorlyposteriorly = subscapularis tear = subscapularis tear

Wrights testWrights test extension, abduction, extension, abduction, loss of loss of pulse, pulse,

external rotation of arm, reproduction of external rotation of arm, reproduction of sympsymp

neck rotated awayneck rotated away = thoracic = thoracic outlet syndoutlet synd

Anterior Glenohumeral Anterior Glenohumeral Dislocation Dislocation

“Shoulder dislocation”“Shoulder dislocation” Mechanism of injury:Mechanism of injury:

From From external rotation or abduction force external rotation or abduction force on humeruson humerus

From a direct posterior blow to proximal From a direct posterior blow to proximal humerushumerus

From a posterolateral blow on the shoulderFrom a posterolateral blow on the shoulder Exam:Exam:

Space underneath acromion where Space underneath acromion where humeral head should liehumeral head should lie

Palpable anterior mass representing Palpable anterior mass representing humeral head in anterior axillahumeral head in anterior axilla

Tx:Tx: Closed reductionClosed reduction Immobilization in internal rotationImmobilization in internal rotation

Types of closed Types of closed reductionreduction Stimson maneuver:Stimson maneuver:

Pt prone on table with weight on armPt prone on table with weight on arm Mitch maneuver:Mitch maneuver:

Pt supine, steady downward traction Pt supine, steady downward traction applied at elbow, combined with slow applied at elbow, combined with slow gradual external rotation and abduction of gradual external rotation and abduction of limblimb

Hippocratic maneuver:Hippocratic maneuver: Pt supine, examiner places sole of foot in Pt supine, examiner places sole of foot in

axilla (shoe removed), grabs pt’s wrist with axilla (shoe removed), grabs pt’s wrist with both hands and applies steady longitudinal both hands and applies steady longitudinal tractiontraction

Traction/ countertraction:Traction/ countertraction: Sheet method 2 people opposingSheet method 2 people opposing

Scapular manipulationScapular manipulation Stimson maneuver with medial Stimson maneuver with medial

manipulation of tip of scapulamanipulation of tip of scapula

Anterior Glenohumeral Anterior Glenohumeral DislocationDislocation

2 lesions with recurrent 2 lesions with recurrent dislocations:dislocations: Bankhart Lesion:Bankhart Lesion:

Anterior capsular injury assoc with a Anterior capsular injury assoc with a tear of the glenoid labrum off the tear of the glenoid labrum off the anterior glenoid rimanterior glenoid rim

Hill-Sachs Lesion:Hill-Sachs Lesion: Compression fracture of the articular Compression fracture of the articular

surface of the humeral head surface of the humeral head posterolaterlaterally that is created posterolaterlaterally that is created by the sharp edge of the anterior by the sharp edge of the anterior glenoid as the humeral head glenoid as the humeral head dislocates over itdislocates over it

Glenoid Labrum InjuryGlenoid Labrum Injury

From repeated anterior subluxation From repeated anterior subluxation of the shoulderof the shoulder

From anterior instability during From anterior instability during acceleration phase of throwing acceleration phase of throwing secondary to long head of biceps secondary to long head of biceps pulling on anterior labrumpulling on anterior labrum

From repetitive bench pressing and From repetitive bench pressing and overhead pressingoverhead pressing

From fall on outstretched armFrom fall on outstretched arm

Glenoid Labrum InjuryGlenoid Labrum Injury Patient c/o pain that interrupts Patient c/o pain that interrupts

smooth functioning of shoulder during smooth functioning of shoulder during performance of specific activityperformance of specific activity

Exam:Exam: Pain on forced external rotation @ 90 Pain on forced external rotation @ 90

degrees abductiondegrees abduction ““pop” or “click” on forced external pop” or “click” on forced external

rotationrotation Weakness of rotator cuff musclesWeakness of rotator cuff muscles

CT scan or MRI with contrast may CT scan or MRI with contrast may allow early detectionallow early detection

Tx:Tx: Physical therapyPhysical therapy Arthroscopic repairArthroscopic repair

Rotator CuffRotator Cuff

The rotator cuff connects the The rotator cuff connects the humerus to the scapula. humerus to the scapula.

The rotator cuff is formed by the The rotator cuff is formed by the tendons of four muscles: tendons of four muscles: the the supraspinatus, supraspinatus, infraspinatus, infraspinatus, teres minor,teres minor, and and subscapularis.subscapularis.

BursitisBursitis

BursitisBursitis Bursitis is defined as inflammation of a bursa. Bursitis is defined as inflammation of a bursa. Bursae are closed, round, flattened sacs that are lined by Bursae are closed, round, flattened sacs that are lined by

synovium and separate bare areas of bone from overlapping synovium and separate bare areas of bone from overlapping muscles (deep bursae) or skin and tendons (superficial bursae). muscles (deep bursae) or skin and tendons (superficial bursae).

They occur at areas of friction or possible impingement. They occur at areas of friction or possible impingement. Bursae function to reduce friction and allow a greater range of Bursae function to reduce friction and allow a greater range of

movement when muscle contracts. movement when muscle contracts. They may or may not communicate with the adjacent joint space. They may or may not communicate with the adjacent joint space.

Symptoms of bursitis include inflammation, localized tenderness, Symptoms of bursitis include inflammation, localized tenderness, warmth, edema, erythema of the skin (if superficial), and loss of warmth, edema, erythema of the skin (if superficial), and loss of function function

When inflamed, the synovial cells increase in thickness and may When inflamed, the synovial cells increase in thickness and may show villous hyperplasia. show villous hyperplasia.

Bursal lining eventually may be replaced by granulation tissue Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue formation. prior to fibrous tissue formation.

The bursa becomes filled with fluid, which is often rich in fibrin. The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage sometimes occurs. Hemorrhage sometimes occurs.

Patients often complain of a dull shoulder ache. Patients often complain of a dull shoulder ache. The most common symptom of subacromial bursitis is tenderness The most common symptom of subacromial bursitis is tenderness

over the greater trochanter (and beneath the deltoid muscle) that over the greater trochanter (and beneath the deltoid muscle) that disappears when the arm is abducted. disappears when the arm is abducted.

Clavicle fractureClavicle fracture Most common bone fracturedMost common bone fractured The weakest part being the junction of the middle and The weakest part being the junction of the middle and

lateral thirdslateral thirds Class A (middle third fractures) (80%): Class A (middle third fractures) (80%):

Treat with sling immobilization. Treat with sling immobilization. Some prefer using a figure-eight clavicular splint, especially Some prefer using a figure-eight clavicular splint, especially

for displaced fractures.for displaced fractures. Class B (distal third fractures) (15%): Class B (distal third fractures) (15%):

Treat type I (nondisplaced) and type III (articular surface) Treat type I (nondisplaced) and type III (articular surface) fractures with sling immobilization. fractures with sling immobilization.

Immobilize type II (displaced) fractures in a sling and swathe. Immobilize type II (displaced) fractures in a sling and swathe. These may require orthopedic surgical fixation.These may require orthopedic surgical fixation.

Class C (proximal third) (5%): Class C (proximal third) (5%): Treat nondisplaced fractures with sling immobilization. Treat nondisplaced fractures with sling immobilization. Displaced injuries may require orthopedic referral for surgical Displaced injuries may require orthopedic referral for surgical

reduction. reduction. Neonatal fractures generally heal spontaneously in several Neonatal fractures generally heal spontaneously in several

weeks without special treatment.weeks without special treatment.

Normal-----Normal-----

----------NormalNormal

FRACTUREFRACTURE--------

Acromio-clavicular Acromio-clavicular (AC) separation (AC) separation

(separated shoulder)(separated shoulder) Mechanism of injury- Mechanism of injury- fall onto point of shoulderfall onto point of shoulder If there has been significant disruption (or a If there has been significant disruption (or a

fracture to the clavicle itself), the area will fracture to the clavicle itself), the area will appear swollen and deformed compared with appear swollen and deformed compared with the other side. the other side.

The patient will avoid movement, do to pain. The patient will avoid movement, do to pain. Gently have the patient move their arm across Gently have the patient move their arm across

their chest while you palpate in the AC region. their chest while you palpate in the AC region. This will cause pain specifically at the AC joint if This will cause pain specifically at the AC joint if

there is separation. there is separation. Tenderness is felt at the junction, or the site of Tenderness is felt at the junction, or the site of

the AC (acromioclavicular) jointthe AC (acromioclavicular) joint. .

Paralysis of the Serratus Paralysis of the Serratus AnteriorAnterior

Results from injury to the Results from injury to the long long thoracic nervethoracic nerve causing causing a a “Winging of “Winging of the Scapula”the Scapula”

IITTAALLYY

TREVI FOUNTAIN ROMATREVI FOUNTAIN ROMA

FONTANA DI TREVIFONTANA DI TREVI

Brachial Plexus InjuriesBrachial Plexus Injuries Disease, stretching, and wounds in the Disease, stretching, and wounds in the

posterior triangle of the neckposterior triangle of the neck Injuries to the brachial plexus result in Injuries to the brachial plexus result in

paralysis and anesthesia.paralysis and anesthesia. Superior trunk injuries Superior trunk injuries (C5-6):(C5-6): “Waiter’s tip“Waiter’s tip” ”

position (Erb-Duchenne palsy) position (Erb-Duchenne palsy) Fall (motorcycle), newborn forced delivery Fall (motorcycle), newborn forced delivery

(stretched neck), heavy backpacks (stretched neck), heavy backpacks Inferior injuries Inferior injuries (C8-T1(C8-T1): ): “Claw hand”“Claw hand”

(Klumpke paralysis)(Klumpke paralysis) Arm jerked superiorly, grabbing tree branch while Arm jerked superiorly, grabbing tree branch while

falling, pulling on baby’s upper ext during falling, pulling on baby’s upper ext during childbirth.childbirth.

Bicipital TendonitisBicipital Tendonitis

Pain localized to proximal Pain localized to proximal humerus and shoulder joint, with humerus and shoulder joint, with resistive supination of the resistive supination of the forearm aggravating symptomsforearm aggravating symptoms

+ Yergason test+ Yergason test (resisted (resisted supination) for unstable long supination) for unstable long head of biceps in bicipital groovehead of biceps in bicipital groove

Tx:Tx: Physical therapyPhysical therapy Activity modificationActivity modification NSAID’sNSAID’s

Shoulder FracturesShoulder Fractures Proximal Humerus Fractures:Proximal Humerus Fractures:

Neer classificaton:Neer classificaton: Non-displaced fractures: Non-displaced fractures:

are displaced less than 1cm or angulated <45 degrees, are displaced less than 1cm or angulated <45 degrees, regardless of the fracture pattern or # of fragmentsregardless of the fracture pattern or # of fragments

Displaced fractures:Displaced fractures: 2 part2 part fx’s are fractured either through the anatomical fx’s are fractured either through the anatomical

neck, surgical neck, greater tuberosity or lesser neck, surgical neck, greater tuberosity or lesser tuberositytuberosity

3 part3 part fx’s are fx’s of the surgical neck with fractures of fx’s are fx’s of the surgical neck with fractures of either the greater tuberosity or lesser tuberosityeither the greater tuberosity or lesser tuberosity

4 part4 part fx’s are fxs of the anatomic neck & fractures of fx’s are fxs of the anatomic neck & fractures of the greater and lesser tuberositiesthe greater and lesser tuberosities

Humeral FracturesHumeral Fractures

Neurovascular status must be Neurovascular status must be evaluated with fracturesevaluated with fractures

The humerus is in direct contact The humerus is in direct contact with nerves that can be injured with nerves that can be injured due to a fracture.due to a fracture. Surgical neckSurgical neck: axillary nerve : axillary nerve (C5-6, (C5-6,

deltoid atrophy) (also from improper deltoid atrophy) (also from improper crutch use “waiter’s tip”)crutch use “waiter’s tip”)

Radial groove: Radial groove: radial nerveradial nerve Distal end of humerusDistal end of humerus: median nerve: median nerve Medial epicondyle: Medial epicondyle: ulnar nerveulnar nerve

Proximal Humerus FractureProximal Humerus Fracture The vascularity is at risk with anatomical The vascularity is at risk with anatomical

neck fracturesneck fractures Most common mechanism of injury= Most common mechanism of injury=

FOOSHFOOSH Signs & symptoms:Signs & symptoms:

Pain, swelling, tenderness Pain, swelling, tenderness Tx:Tx:

For nondisplaced fx’s= sling, begin ROM For nondisplaced fx’s= sling, begin ROM exercisesexercises

2 part/3 part fx’s= closed reduction, sling, 2 part/3 part fx’s= closed reduction, sling, possible ORIFpossible ORIF

Absolute indication for hemi-arthroplasty: 4 Absolute indication for hemi-arthroplasty: 4 part fx’s, non-reducible 3 part fx’spart fx’s, non-reducible 3 part fx’s

FOOSH = Fall On Outstretched HandFOOSH = Fall On Outstretched Hand

Midshaft Humerus Midshaft Humerus FracturesFractures Signs & Symptoms:Signs & Symptoms:

Arm pain, swelling, deformityArm pain, swelling, deformity The arm is shortened with gross motion & The arm is shortened with gross motion &

crepitus on gentle manipulationcrepitus on gentle manipulation XR:XR:

AP/lat c shoulder & elbowAP/lat c shoulder & elbow Tx:Tx:

Coaptation splintCoaptation splint Carefully molded plaster slab placed around Carefully molded plaster slab placed around

medial & lateral aspects of arm, extending from medial & lateral aspects of arm, extending from axilla around elbow & over deltoid & acromion x axilla around elbow & over deltoid & acromion x 2 wks2 wks

Change to Sarmiento brace @ 2 wksChange to Sarmiento brace @ 2 wks May require ORIF with plate/screw or May require ORIF with plate/screw or

intramedullary nailingintramedullary nailing

Midshaft humerus fxMidshaft humerus fx

Distal Humerus Distal Humerus FractureFracture

Supracondylar fx’s of the Humerus:Supracondylar fx’s of the Humerus: Characterized by dissociation b/t diaphysis Characterized by dissociation b/t diaphysis

& condyles of distal humerus, frequently & condyles of distal humerus, frequently extended distally & involves articular extended distally & involves articular surfacesurface

Caused by FOOSH or direct blowCaused by FOOSH or direct blow PE:PE:

+ deformity, instability, crepitus+ deformity, instability, crepitus XR:XR:

AP/lat/obliqAP/lat/obliq Management:Management:

Initial: alignment, immobilization, ice, long arm Initial: alignment, immobilization, ice, long arm splintsplint

Definitive: ORIF, early motionDefinitive: ORIF, early motion

(Other fx’s: transcondylar, medial (Other fx’s: transcondylar, medial condyle, lateral condyle)condyle, lateral condyle)

MONTMARTMONTMARTRERE

PARISPARIS

FRANCEFRANCE

Radial Head FractureRadial Head Fracture MOI:MOI:

Fall forward with elbow extended, forearm Fall forward with elbow extended, forearm pronatedpronated

Pain localized to radial headPain localized to radial head XR:XR:

AP/lat/obliqAP/lat/obliq TX:TX:

Types I, II, & III without mechanical block are Types I, II, & III without mechanical block are treated with a sling and AROM x 3 wkstreated with a sling and AROM x 3 wks

After 3 wks d/c sling & begin aggressive PTAfter 3 wks d/c sling & begin aggressive PT Fx’s with elbow instability or mechanical block Fx’s with elbow instability or mechanical block

are treated operatively with either reduction & are treated operatively with either reduction & fixation of head, excision of head, or ligament fixation of head, excision of head, or ligament repairrepair

Olecranon FracturesOlecranon Fractures

Pain @ elbow with h/o traumaPain @ elbow with h/o trauma XR:XR:

AP/lat/obliqAP/lat/obliq ManagementManagement

Initial: sling for comfortInitial: sling for comfort Definitive: Definitive:

non-displaced fx’s can be managed non-displaced fx’s can be managed with posterior splint @ 90 degrees with posterior splint @ 90 degrees flexion x 2 wksflexion x 2 wks

Other fx’s are managed with ORIF or Other fx’s are managed with ORIF or percutaneous pinning & early motion percutaneous pinning & early motion post-operativelypost-operatively

Nursemaid’s ElbowNursemaid’s Elbow

Subluxation of the radial head from Subluxation of the radial head from the Annular ligamentthe Annular ligament

MC from sudden jerking of child’s MC from sudden jerking of child’s hand while in pronationhand while in pronation

Elbow FracturesElbow Fractures Monteggia FractureMonteggia Fracture

Usually a fx of Usually a fx of the the mid or proximal ulna mid or proximal ulna with anterior dislocation of the radial headwith anterior dislocation of the radial head

MOI:MOI: Forceful pronation or direct blow to dorsum of Forceful pronation or direct blow to dorsum of

ulnaulna H&P:H&P:

Pain & h/o trauma, may have obvious Pain & h/o trauma, may have obvious deformitydeformity

XR:XR: AP/lat/obliqAP/lat/obliq

TX:TX: Hematoma block, reduction, long arm cast or Hematoma block, reduction, long arm cast or

splintsplint May require ORIFMay require ORIF

Galeazzi Galeazzi Fracture/dislocationFracture/dislocation

An injury pattern involving a An injury pattern involving a radial shaft radial shaft fracture with associated dislocation of the fracture with associated dislocation of the distal radioulnar jointdistal radioulnar joint (DRUJ), which (DRUJ), which disrupts the forearm axis joint. disrupts the forearm axis joint.

"fracture of necessity" "fracture of necessity" refers to the adult refers to the adult Galeazzi fracture not being amenable to Galeazzi fracture not being amenable to treatment by closed means, necessitating treatment by closed means, necessitating surgical stabilization. surgical stabilization.

Galeazzi Galeazzi (Reverse (Reverse

Monteggia)Monteggia)

SAN CARLOS DE BARILOCHESAN CARLOS DE BARILOCHE

ARGENTINAARGENTINA

Lateral Epicondylitis Lateral Epicondylitis (Tennis Elbow)(Tennis Elbow)

Pain at lateral humeral Pain at lateral humeral epicondyle, epicondyle, reproduced by reproduced by extending the wrist against extending the wrist against resistanceresistance

Seen in patients who perform Seen in patients who perform repetitive wrist extension (Tennis)repetitive wrist extension (Tennis)

Tx:Tx: NSAID’s, Restriction band, Physical NSAID’s, Restriction band, Physical

therapy, lighter racquet, correction therapy, lighter racquet, correction of backhand strokeof backhand stroke

Medial EpicondylitisMedial Epicondylitis(Pitcher’s Elbow, Golfer’s)(Pitcher’s Elbow, Golfer’s)

Pain at medial humeral epicondylePain at medial humeral epicondyle Seen in patients who golf, or Seen in patients who golf, or

perform throwing sports, such as perform throwing sports, such as baseball, football, javelinbaseball, football, javelin

Tx:Tx: NSAID’s, Physical therapyNSAID’s, Physical therapy

Movements at the wristMovements at the wrist

Radial deviation (abduction)Radial deviation (abduction) Ulnar deviation (adduction)Ulnar deviation (adduction) FlexionFlexion ExtensionExtension SupinationSupination PronationPronation Combination of all of the aboveCombination of all of the above

Distal Forearm Distal Forearm FracturesFractures 1. Extension fractures: 1. Extension fractures:

Colles FractureColles Fracture Extra-articular fx with Extra-articular fx with dorsal dorsal

displacement of distal radiusdisplacement of distal radius MC fx of the wristMC fx of the wrist Usually Usually 2° to FOOSH2° to FOOSH Exam:Exam:

Silver fork deformitySilver fork deformity, swelling, , swelling, decreased ROM secondary to decreased ROM secondary to painpain

XR:XR: AP/true lateral/obliq- radius AP/true lateral/obliq- radius

will be shortenedwill be shortened

Colles fx

Distal Forearm Fractures Distal Forearm Fractures (cont)(cont)

2. 2. Non-displaced Distal Radius Fx’sNon-displaced Distal Radius Fx’s Require short arm cast (SAC) in neutral, Require short arm cast (SAC) in neutral,

ice, elevation, NSAIDS, analgesiaice, elevation, NSAIDS, analgesia 3. 3. Other common fx’s:Other common fx’s:

Smith’s fxSmith’s fx Reverse Colles fxReverse Colles fx Fracture of the distal radius with palmar Fracture of the distal radius with palmar

displacement of the distal fragment.displacement of the distal fragment. Die Punch FxDie Punch Fx

Intra-articular distal radius fx with impaction Intra-articular distal radius fx with impaction of the dorsal aspect of the lunate fossaof the dorsal aspect of the lunate fossa

Barton’s FxBarton’s Fx Displaced intra-articular lip fx of the distal Displaced intra-articular lip fx of the distal

radius radius May be assoc with carpal subluxationMay be assoc with carpal subluxation May be dorsal or volar configurationMay be dorsal or volar configuration Extends into radio-carpal jointExtends into radio-carpal joint

Non-displaced distal radius Non-displaced distal radius fxfx

Smith’s fxSmith’s fx

Die Punch FxDie Punch Fx

Barton’s FxBarton’s Fx

ROSETTE ROSETTE OFOF

NOTRE DOMENOTRE DOME

PARISPARIS

FRANCEFRANCE

Scaphoid FracturesScaphoid Fractures MC fx’d carpal boneMC fx’d carpal bone There is no direct blood supply to the There is no direct blood supply to the proximal proximal

portionportion of the scaphoid of the scaphoid Therefore, scaphoid fx’s have a tendency to Therefore, scaphoid fx’s have a tendency to

develop develop delayed union or delayed union or avascular avascular necrosisnecrosis

Remember the more proximal the fx line is in Remember the more proximal the fx line is in the scaphoid injuries, the greater the the scaphoid injuries, the greater the likelyhood of avascular necrosislikelyhood of avascular necrosis

Mechanism of injuryMechanism of injury Forceful hyperextension of the wristForceful hyperextension of the wrist

Scaphoid FracturesScaphoid Fractures Exam: Exam:

+ snuffbox tenderness+ snuffbox tenderness,, radial deviation of wrist will probably elicit painradial deviation of wrist will probably elicit pain

XR:XR: Obtain AP/lat/obliq/scaphoid viewsObtain AP/lat/obliq/scaphoid views Plain x-ray may not demonstrate fx for up to 4 wksPlain x-ray may not demonstrate fx for up to 4 wks If x-rays are still negative at 10-14 days & pt is If x-rays are still negative at 10-14 days & pt is

symptomatic, obtain bone scan for definitive symptomatic, obtain bone scan for definitive diagnosisdiagnosis

Tx:Tx: Initially in ER:Initially in ER:

Thumb spica (*always tx snuffbox tenderness, even if x-ray Thumb spica (*always tx snuffbox tenderness, even if x-ray neg)neg)

Definitive: Definitive: Long arm thumb spica cast x 4-8 wks.Long arm thumb spica cast x 4-8 wks. If scaphoid is displaced, may require ORIFIf scaphoid is displaced, may require ORIF

A. ThumbA. ThumbB. IndexB. IndexC. Middle fingerC. Middle fingerD. Ring fingerD. Ring fingerE. Little finger E. Little finger

I-V. Metacarpal bonesI-V. Metacarpal bones 1,4. Distal phalanx1,4. Distal phalanx

2. Middle phalanx2. Middle phalanx3,5. Proximal phalanx3,5. Proximal phalanx6. Sesamoid bones6. Sesamoid bones7. Distal interphalangeal joint 7. Distal interphalangeal joint (DIP)(DIP)8. Proximal interphalangeal joint 8. Proximal interphalangeal joint (PIP)(PIP)9. Metacarpophalangeal joint (V.)9. Metacarpophalangeal joint (V.)10. Carpometacarpal joints10. Carpometacarpal joints

11. Trapezium11. Trapezium12. Trapezoid12. Trapezoid13. Capitate13. Capitate14. Hamate14. Hamate15. Scaphoid15. Scaphoid16. Lunate16. Lunate17. Triquetrum17. Triquetrum18. Pisiform 18. Pisiform

19. Radius 19. Radius 20. Ulna 20. Ulna

Metacarpal Neck FracturesMetacarpal Neck Fractures

Boxer’s fx :Boxer’s fx : Most frequently occur at Most frequently occur at the 5the 5thth metacarpal, metacarpal, as a result of a direct as a result of a direct blow delivered to the hand or by the blow delivered to the hand or by the hand to a solid (animate or inanimate) hand to a solid (animate or inanimate) object while the hand is held in a fist object while the hand is held in a fist

Metacarpal Neck Fx’sMetacarpal Neck Fx’s(Boxer’s fx) (Boxer’s fx)

Fractures with angulation <15 degrees Fractures with angulation <15 degrees should be immobilized in an ulnar gutter should be immobilized in an ulnar gutter splint encasing both the 4splint encasing both the 4thth & 5 & 5thth fingers with fingers with the mcp joint flexed as close to 90 degrees as the mcp joint flexed as close to 90 degrees as possible & wrist held in slight extensionpossible & wrist held in slight extension

Fx’s with angulation >15 degrees &/or with Fx’s with angulation >15 degrees &/or with rotational deformity of the finger should be rotational deformity of the finger should be reduced & casted/splinted in the reduced & casted/splinted in the aforementioned positionaforementioned position

Post reduction films should be obtainedPost reduction films should be obtained Unstable fx’s or fx’s that are not reduced to Unstable fx’s or fx’s that are not reduced to

an acceptable position may require an acceptable position may require percutaneous pinningpercutaneous pinning

Boutonniere DeformityBoutonniere Deformity Disruption of the central slip of the Extensor Disruption of the central slip of the Extensor

Digitorum Communis tendon from its insertion Digitorum Communis tendon from its insertion at the dorsal base of the middle phalanx that at the dorsal base of the middle phalanx that results in results in

a a flexed PIP joint & hyperextended flexed PIP joint & hyperextended DIP joint DIP joint

The deformity may not be present at the time The deformity may not be present at the time of injury & usually develops over 10-21 daysof injury & usually develops over 10-21 days

Tx:Tx: 1. Splint PIP joint into full extension with passive & 1. Splint PIP joint into full extension with passive &

active flexion of DIP jointactive flexion of DIP joint 2. Insert K-wire to PIP joint to hold extension, 2. Insert K-wire to PIP joint to hold extension, 3. continue passive & active flexion at DIP joint3. continue passive & active flexion at DIP joint 4. direct tendon repair & splinting4. direct tendon repair & splinting

Mallet FingerMallet Finger

Disruption of the extensor tendon Disruption of the extensor tendon over the distal phalanx with over the distal phalanx with flexion flexion at the DIP joint & extension or at the DIP joint & extension or hyperextension at the PIP jointhyperextension at the PIP joint

Tx:Tx: 1. splint with hyperextension of the DIP 1. splint with hyperextension of the DIP

joint, flexion of the PIP jointjoint, flexion of the PIP joint 2. Hold with K-wire2. Hold with K-wire 3. Direct tendon repair & splinting3. Direct tendon repair & splinting

Flexor TenosynovitisFlexor Tenosynovitis Infection of the digital synovial sheaths.Infection of the digital synovial sheaths. Usually confined to affected fingerUsually confined to affected finger

ExceptExcept in in pinky and thumbpinky and thumb, can spread to palm, and , can spread to palm, and forearmforearm

Diagnosis is made on four classic findingsDiagnosis is made on four classic findings.. 1. tenderness over flexor tendon 1. tenderness over flexor tendon

sheathsheath 2. symmetric swelling of the finger 2. symmetric swelling of the finger

(sausage finger)(sausage finger) 3. pain with passive extension3. pain with passive extension 4. flexed posture of the involved digit 4. flexed posture of the involved digit

at restat rest

Trigger fingerTrigger finger Trigger finger is a painful condition caused by a Trigger finger is a painful condition caused by a

narrowing of the sheath that surrounds the finger narrowing of the sheath that surrounds the finger tendon. tendon.

Inflammation due to overuse is usually the cause.Inflammation due to overuse is usually the cause. Tendons slide through a snug tunnelTendons slide through a snug tunnel. . Irritation as the tendons slip into the tunnel can cause Irritation as the tendons slip into the tunnel can cause

the opening of the tunnel to become smaller, or the the opening of the tunnel to become smaller, or the tendon to thicken so that it can't easily pass through tendon to thicken so that it can't easily pass through the tunnel. the tunnel.

As you try to straighten the finger, the tendon becomes As you try to straighten the finger, the tendon becomes momentarily stuck at the mouth of the tunnel then momentarily stuck at the mouth of the tunnel then pops as the tendon slips past the tight area. pops as the tendon slips past the tight area.

No X-rays or other testing are usually needed No X-rays or other testing are usually needed Tx:Tx:

NSAID’s, splint, cortisol injection, surgical releaseNSAID’s, splint, cortisol injection, surgical release

Game Keeper’s ThumbGame Keeper’s ThumbSkier’s ThumbSkier’s Thumb

Injury to the Injury to the ulnar collateral ligament of the MCP ulnar collateral ligament of the MCP joint of the thumbjoint of the thumb

Destroys joint stabilityDestroys joint stability Impairs ability to pinchImpairs ability to pinch Evaluation:Evaluation: Stress ulnar aspect of the MCP joint by forcing thumb Stress ulnar aspect of the MCP joint by forcing thumb

into radial abduction into radial abduction If there is <15 degrees of side to side difference (one thumb If there is <15 degrees of side to side difference (one thumb

compared to the other) or an opening > 45 degrees at the compared to the other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical repair is requiredulnar aspect of the MCP joint, surgical repair is required

Closed tx with a thumb spica cast or splint with the thumb Closed tx with a thumb spica cast or splint with the thumb slightly adducted may allow for healing of an incomplete tearslightly adducted may allow for healing of an incomplete tear

Game Keeper’s Game Keeper’s ThumbThumb

(occupation, over (occupation, over periodperiod

of time)of time)

Skier’s ThumbSkier’s Thumb

(sport, acutely) (sport, acutely)

De Quervain’s De Quervain’s TenosynovitisTenosynovitis

The disease is an entrapment tendonitis of the The disease is an entrapment tendonitis of the tendons contained within the first dorsal tendons contained within the first dorsal compartment at the wrist, resulting in pain compartment at the wrist, resulting in pain with thumb motion.with thumb motion.

The most classic finding in de Quervain The most classic finding in de Quervain tenosynovitis is a tenosynovitis is a positive positive Finkelstein testFinkelstein test. . Perform the Finkelstein test by having the patient Perform the Finkelstein test by having the patient

make a fist with the thumb inside the fingers. make a fist with the thumb inside the fingers. The clinician then applies passive ulnar deviation of The clinician then applies passive ulnar deviation of

the wrist to reproduce the chief complaint of the wrist to reproduce the chief complaint of dorsolateral wrist pain.dorsolateral wrist pain.

Tx:Tx: Splinting of the thumb and wrist relieves symptoms Splinting of the thumb and wrist relieves symptoms

(although noncompliance rates are high)(although noncompliance rates are high) NSAIDSNSAIDS Corticosteroid injectionCorticosteroid injection Surgical releaseSurgical release

PositivePositive

Finkelstein Finkelstein testtest..

ParonychiaParonychia A paronychia is a superficial infection of A paronychia is a superficial infection of

epithelium epithelium lateral to the nail platelateral to the nail plate. . The acute painful purulent infection is most The acute painful purulent infection is most

frequently caused by staphylococci. frequently caused by staphylococci. The patient's condition and discomfort are The patient's condition and discomfort are

markedly improved by a simple drainage markedly improved by a simple drainage procedure procedure

FelonFelon Felons are closed-space infections of the Felons are closed-space infections of the fingertip fingertip

pulppulp. . Fingertip pulp is divided into numerous small Fingertip pulp is divided into numerous small

compartments by vertical septa that stabilize the pad. compartments by vertical septa that stabilize the pad. Infection occurring within these compartments can Infection occurring within these compartments can

lead to abscess formation, edema, and rapid lead to abscess formation, edema, and rapid development of increased pressure in a closed space. development of increased pressure in a closed space.

This increased pressure may compromise blood flow This increased pressure may compromise blood flow and lead to necrosis of the skin and pulp.and lead to necrosis of the skin and pulp.

Herpetic WhitlowHerpetic Whitlow Herpes simplex virus may cause an intense, Herpes simplex virus may cause an intense,

painful skin infection. painful skin infection. The fingertip is sore and swollen but is not as The fingertip is sore and swollen but is not as

firm as in a felon. firm as in a felon. The appearance of The appearance of tiny fluid-filled blebs tiny fluid-filled blebs

(vesicles) on the fingers is diagnostic(vesicles) on the fingers is diagnostic. . A herpetic whitlow is often mistaken for a felon. A herpetic whitlow is often mistaken for a felon. The disorder eventually goes away on its own. The disorder eventually goes away on its own. Surgery is not needed.Surgery is not needed.

INFECTIONS CAUSED BY INFECTIONS CAUSED BY BITESBITES The most common cause is injury to the knuckles The most common cause is injury to the knuckles

by the teeth from a punch to the mouth. by the teeth from a punch to the mouth. Animal bites are also common causes. Animal bites are also common causes. Wound contamination by a number of types of Wound contamination by a number of types of

bacteria can result from human and animal bites. bacteria can result from human and animal bites. All bite injuries are potentially dangerous and can All bite injuries are potentially dangerous and can

cause significant infection. cause significant infection. The injured area should be cleaned surgically, The injured area should be cleaned surgically,

with the wound left open. with the wound left open. Antibiotics should be given to prevent joint Antibiotics should be given to prevent joint

infection (septic arthritis), which can otherwise infection (septic arthritis), which can otherwise lead to permanent destruction of the knuckle lead to permanent destruction of the knuckle joints. joints.

Bacteria in human and animal bites are resistant Bacteria in human and animal bites are resistant to many antibiotics but are generally sensitive to to many antibiotics but are generally sensitive to

ampicillin and penicillin. and penicillin. (in practice use: augmentin)(in practice use: augmentin)

The HandThe Hand Nerves:Nerves:

RadialRadial:: Provides sensation to dorsum of hand on radial side of third Provides sensation to dorsum of hand on radial side of third

metacarpal & dorsal thmb, index, & middle fingers as far as the metacarpal & dorsal thmb, index, & middle fingers as far as the distal phalanges.distal phalanges.

The first web space is the most ‘pure’ area to test radial nerve The first web space is the most ‘pure’ area to test radial nerve sensation.sensation.

Motor= test thumb extension- hitchikingMotor= test thumb extension- hitchiking UlnarUlnar::

Provides sensation to the ulnar side of hand (dorsal & palmar), Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little fingers.ring & little fingers.

The volar tip of the little finger is the most ‘pure’ area to test The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve sensationulnar nerve sensation

Motor= test opposition (little finger), finger adductionMotor= test opposition (little finger), finger adduction MedianMedian::

Provides sensation to palm & palmar surface of thumb, index, Provides sensation to palm & palmar surface of thumb, index, middle, & half of ring finger; may supply dorsum of terminal middle, & half of ring finger; may supply dorsum of terminal phalanges of these fingersphalanges of these fingers

The distal palmer aspect of the index finger is the most ‘pure’ The distal palmer aspect of the index finger is the most ‘pure’ area to test median nerve sensationarea to test median nerve sensation

Motor= test opposition (thumb)Motor= test opposition (thumb)

UE Arteries & NervesUE Arteries & Nerves

Crutch misuseCrutch misuse Thoracic Outlet ObstructionThoracic Outlet Obstruction Carpal TunnelCarpal Tunnel Cubital TunnelCubital Tunnel Saturday Night PalsySaturday Night Palsy

Thoracic Outlet SyndromeThoracic Outlet Syndrome Usually resulting Usually resulting from irritation of C8 and from irritation of C8 and

T1 innervated nerves, T1 innervated nerves, may be caused by may be caused by

a cervical rib, a cervical rib, a fiber spanning from a rudimentary cervical rib, a fiber spanning from a rudimentary cervical rib, tendinous bands from the scalenus anterior to tendinous bands from the scalenus anterior to

the medius muscles or the medius muscles or hypertrophic clavicle fracture callushypertrophic clavicle fracture callus

Neurologic, venous, or arterial symptomsNeurologic, venous, or arterial symptoms Tx:Tx:

Postural exercisesPostural exercises Surgical resection of cervical rib, first rib, or Surgical resection of cervical rib, first rib, or

scalenotomyscalenotomy

Carpal TunnelCarpal Tunnel The syndrome is characterized by pain, The syndrome is characterized by pain,

paresthesias, and weakness in paresthesias, and weakness in the the median nervemedian nerve distribution of the hand. distribution of the hand.

Trauma vs. repetitive motionTrauma vs. repetitive motion Acute CTS can be thought of as a compartment Acute CTS can be thought of as a compartment

syndrome of the carpal canal, and decompression syndrome of the carpal canal, and decompression should be performed as soon as possible should be performed as soon as possible

Tinel’s and Phalen’s testsTinel’s and Phalen’s tests, nerve conduction studies, nerve conduction studies Tx:Tx:

Steroid inj, splinting, NSAID’s, surgical releaseSteroid inj, splinting, NSAID’s, surgical release

Cubital Tunnel SyndromeCubital Tunnel Syndrome

is the effect of pressure on the is the effect of pressure on the “funny bone” “funny bone” causing pain, causing pain, paresthesia’s to the paresthesia’s to the ulnar nerve ulnar nerve distributiondistribution

Saturday Night Palsy Saturday Night Palsy The patient has injured his upper arm, usually The patient has injured his upper arm, usually

by sleeping with his arm over the back of a by sleeping with his arm over the back of a chair, and now presents holding the affected chair, and now presents holding the affected hand and wrist with his good hand, hand and wrist with his good hand, complaining of complaining of decreased or absent sensation decreased or absent sensation on the radial and dorsal side of his hand and on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, wrist, and of inability to extend his wrist, thumb and finger joints. thumb and finger joints.

With the hand supinated (palm up) and the With the hand supinated (palm up) and the extensors aided by gravity, hand function may extensors aided by gravity, hand function may appear normal, but when the hand is pronated appear normal, but when the hand is pronated (palm down) the wrist (palm down) the wrist and hand will drop.and hand will drop.

Enlargement of the Enlargement of the Lymph Nodes Lymph Nodes

(Lymphadenopathy)(Lymphadenopathy) Infection (streaking)Infection (streaking)

Lymphangitis:Lymphangitis: inflammation of the inflammation of the lymph vessels.lymph vessels.

Breast Ca (sentinel node)Breast Ca (sentinel node) LymphedemaLymphedema

'Excellence is an art won by training and habituation. We do not act 'Excellence is an art won by training and habituation. We do not act rightly becauserightly because

we have virtue or excellence, but rather we have those because we we have virtue or excellence, but rather we have those because we have acted rightly. have acted rightly.

We are what we repeatedly do. Excellence, then, is not an act but a We are what we repeatedly do. Excellence, then, is not an act but a habit.'habit.'

AristotelesAristotelesA journey of a thousand miles begins with a single step. Lao Tsu“I find that the harder I work, the more luck I seem to have”.  Thomas Jefferson

Self conquest is the greatest of victories.Self conquest is the greatest of victories. PlatoPlato ““Imagination is everything. It is the preview of life’s comingImagination is everything. It is the preview of life’s comingattractions.”attractions.” Albert EinsteinAlbert Einstein

Nothing great was ever achieved without enthusiasm. Ralph Waldo

Emerson

““If a man empties his purse into his head, no man can take If a man empties his purse into his head, no man can take it it

away from him. An investment in knowledge always pays the away from him. An investment in knowledge always pays the bestbest

interest” Benjamin Franklininterest” Benjamin Franklin