Musculoskeletal System/Rheumatologic Upper Extremities Bursitis Fractures – wrist ▪ Causes: injury or trauma; prolonged pressure; overuse or ▪ Colle’s Fracture (outward) – wrist gets bent backwards strenuous activity; crystal-induced arthropathy; and ▪ Smith’s Fracture (inward) – wrist gets bent forwards inflammatory arthritis ▪ Results from a fall onto the hand ▪ Swelling, pain ▪ Pain, deformity, MOI ▪ ↓ Active ROM, Full passive ROM o Colles – most common injury of the wrist – distal ▪ NSAIDs radius fracture w/ dorsal angulation ▪ ***The two main indications to aspirate a bursa are to rule out ▪ Dx Xray infection, and to aid in the diagnosis of a microcrystalline ▪ Tx Cast immobilization after reduction disorder like gout. ▪ *** Radius & ulna fractures comprise the largest proportion of fractures (44%) Tendinitis ▪ Most affected group 5-14 years (26%) ▪ NSAIDs & Rest (ice, compression, elevation) ▪ PT/OT or brace may be useful ▪ Achillis tendinitis is a common injury, particularly in sports that involve lunging and jumping ▪ Patellar tendinitis is a common among players with a lot of jumping and landing Strain/sprain – wrist Rotator cuff injuries ▪ Sprain – ligaments ▪ ***“SITS” muscles: Supraspinatus, Infraspinatus, Teres ▪ Strains – muscles, tendons minor, Subscapularis ▪ Acute – athletes, laborer, weekend worrier ▪ **Supraspinatus most commonly injured ▪ Chronic – overuse, repetitive use at work, sports ▪ Rare to have an isolated tear of other muscles ▪ Swelling, pain, tenderness, discoloration of skin, may hear a ▪ Usually tear from abduction and rotation “popping” or tearing inside wrist ▪ Acute shoulder pain, night pain ▪ Clinical dx Xray or MRI to confirm ▪ 90% of acute injuries are exacerbations of a chronic RTC tear ▪ Tx ▪ Inability to abduct arm, externally rotate arm against o Protection splint resistance o Rest ▪ Drop arm test is “+” o Ice through splint ▪ Diffuse atrophy of shoulder musculature o Compression Ace wrap ▪ Dx Xrays helpful to r/o tendonitis, tumors, arthrosis o Elevation above heart o Arthrography or MRI may be used to dx tears ▪ *** If left untreated, can become a SLAC wrist (scapho-lunate ▪ Tx advanced collapse) o pain meds, ice, ortho referral, prevent frozen should or adhesive capsulitis if possible o Want to repair within 3-4 months ▪ Usually >40 y/o Impingement syndrome Adhesive capsulitis ▪ Anything that entraps RTC muscles under acromion ▪ Inflammatory process that may follow injury to the shoulder ▪ HPI: repetitive overhead work or fall on hand or arise on its own ▪ pain at greater tuberosity, lateral shoulder ▪ Characterized by pain and restricted gleno-humeral ▪ Pain and difficulty abducting arm movement ▪ Positive Neer impingement and Hawkins signs ▪ Often preceded by insignificant injury ▪ Dx clinical (MRI to r/o RTC tear if not improving w/ tx) ▪ Decreased shoulder ROM, especially abduction and flexion ▪ Tx: rest, ice, NSAIDs, PT, steroid injections ▪ Passive ROM limited by firm resistance ▪ If not better after 6-12 wks, may consider surgery ▪ Dx o Arthrograthy may show decreased volume of the joint capsule and capsular contraction ▪ Tx o Aggressive home exercise program and PT o Passive ROM, NSAIDs o Operative manipulation when exercises fail o Not a permanent loss of motion! ▪ *** More common in women and diabetics o If they have this on top of an RTC tear, need tear to clear before address this Lateral Epicondylitis (“tennis elbow”) De Quervain’s ▪ Overuse, repetitive supination and wrist extension ▪ A stenosing tenosynovitis – most common tendonitis in wrist ▪ Most common overuse injury of the elbow ▪ Age: 30 – 50, women & diabetics ▪ Point tenderness over lateral epicondyle o Lifting your child repeatedly involves using your ▪ Pain on resisted wrist extension thumbs as leverage ▪ Clinical diagnosis o Jobs or hobbies that involve repetitive hand and o x-ray to r/o arthritis, may show osteophytes overlying wrist motions lateral epicondyle ▪ Painful condition involving tendons on thumb side of wrist o MRI may be useful in demonstrating tendon ▪ difficulty moving thumb/wrist when grasping or pinching disruption ▪ Pain/tenderness/swelling near base of thumb ▪ Tx ▪ Radiation of pain up forearm is common o Rest (at least 6 wks), Ice, NSAIDs ▪ Dx o counter force strap (counterbalance brace) o Swelling and thickening of tendon sheath may be o Steroid injection, a few may require surgery appreciated ▪ ***Extensor muscles attach to the lateral epicondyle o Finkelstein test! Medial Epicondylitis (“golfer’s elbow, baseball elbow”) ▪ Affects the flexor-pronator muscles ▪ Point tenderness over medial epicondyle ▪ Pain on resisted wrist flexion or pronation ▪ Clinical diagnosis (x-ray to r/o arthritis or loose body) o Imaging (xrays) generally NOT needed to diagnose ▪ Tx ▪ Tx o Rest, ice, NSAIDs o Brace/thumb splint o Steroid injection, stretching/strengthening o NSAIDs, PT/OT ▪ *** Flexor muscles attach to the medial epicondyle o Cortisone injection/surgery if needed Olecranon bursitis Carpal tunnel syndrome ▪ Caused by acute injury or repetitive trauma to olecranon ▪ Compression of the median nerve under the transverse bursa; less frequently from skin breaks w/ septic cause (S. carpal ligament aureus) ▪ Can be precipitated by premenstrual fluid retention, early RA, ▪ May be painful, may also look reddened and appear like acromegaly, trauma, pregnancy, repetitive flexion/extension cellulitis of wrist, alcohol abuse ▪ Dx Clinical dx (imaging not usually indicated unless ▪ Diabetes or metabolic disorders that make nerves more suspicion of fracture) susceptible to compression are at higher risk (lupus, RA) ▪ Tx ▪ Sx Pain, night pain, numbness/tingling (paresthesia) in o Sling/pain meds/ice hand & wrist (spare little finger) o Ace wrap (compression) ▪ Dx o Drain if infectious (yellow joint fluid) o Durkan’s test: reproduction of symptoms with o Abx if infectious carpal tunnel compression ▪ *** ROM usually preserved o Phalen’s sign: reproduction of symptoms with wrist hyperflexion o Tinel’s sign: reproduction of symptoms with percussion over carpal tunnel o Flick sign: patient reports shaking of the hand provides relief ▪ Tx NSAIDs, volar splint in neutral position o Surgical intervention may be needed to decompress nerve – 99% curative – most common and successful operative tx of peripheral nerves ▪ ***Most common mononeeuropathy Ganglion cyst Gamekeeper’s thumb (Thumb Sprain) ▪ Noncancerous mass, often on tendons or joints of wrist/hands ▪ Sprain or tear of the ulnar collateral ligament of thumb ▪ Round, small, fluid-filled masses, usually painless (unless ▪ Usually a hx of sprained thumb or fall on hand compressing nerve) ▪ Ligamentous laxity of the ulnar collateral ligament, with ▪ Clinical diagnosis instability and weakness of pinch ▪ Tx ▪ Clinical dx MRI if unstable on exam o Observation & rest - often resolves on its own with ▪ Tx rest o Immobilization with splint o Immobilization o Surgical repair of UCL if complete rupture o Aspiration or surgery if it painful or disabling ▪ Stenner lesion – absolute indication for surgery ▪ *** Most common mass/lump of hand Shoulder Dislocation Clavicle Fracture ▪ Usually anterior ▪ Usually a pediatric fracture ▪ Pt will support affected arm with the other arm ▪ MOI: direct force to lateral shoulder, fall or sporting injury ▪ May have loss of sensation over shoulder due to axillary nerve ▪ Affected extremity held close to body entrapment ▪ Shoulder is slumped downward, forward, and inward ▪ Management Manual relocation, can resolve ▪ Management Immobilization in figure 8 dressing spontaneously after a few weeks Scapula Fracture Humeral Shaft Fracture ▪ MOI: direct violent trauma ▪ Typically from trauma in the elderly ▪ May also have injury to ribs, chest wall, or shoulder girdle ▪ Extensive bruising of upper arm ▪ Shoulder is adducted and arm is held close to the body ▪ Wrist drop from radial nerve damage ▪ Immobilization with sling and swathe dressing ▪ Wrist splinting and casting over site of break Supracondylar Fracture Radial Head Fracture ▪ Pediatric fracture ▪ MOI: FOOSH ▪ Usually involves distal humerus ▪ Decreased ROM in elbow ▪ Limb ischemia if branchial artery is damaged ▪ Difficult to see on x-ray, may see displacement of fat pad, ▪ X-ray showing posterior sail sign, anterior humeral line drawn elbow effusion will not bisect the capitate ▪ Assess neurovascular involvement, check radial pulses! Colles Fracture of Distal Radius Scaphoid Fracture ▪ MOI: FOOSH posterior displacement of wrist (“dinner fork ▪ FOOSH deformity”) ▪ Fullness or pain in the anatomical snuffbox ▪ Casting alone if nondisplaced ▪ Possibly negative x-ray (4 view x-ray - repeat imaging in 10-14 ▪ Closed reduction followed by casting if slightly displaced days if negative) ▪ ORIF & short arm cast if displaced ▪ Management Immobilize in thumb spica ▪ ***Risk of AV necrosis due to poor blood supply Smith Fracture of Distal Radius Boxer’s Fracture of Distal 5th Metacarpal ▪ MOI: opposite Colles = fall on back of hand ▪ MOI: blow of closed fist against another object ▪ Splinting vs percutaneous pinning Lower Extremities Ankle Sprain • Patient with a history of ankle inversion • PE will show pain and swelling • Imaging will show partial or complete tearing of ligaments • Most commonly injured anterior talofibular ligament (ATFL) • Treatment is RICE therapy • Comments: Ottawa Rules to determine imaging OTTAWA RULES: Do ANKLE xray if there is pain in the malleolar region with any of the following: ▪ Bone tenderness @ posterior edge of lateral malleolus ▪ Bone tenderness