Anatomy Lect 7 Ue


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Anatomy Lect 7 Ue

  1. 1. Anatomy Lecture 7 Upper Extremities Physician Assistant Program Miami Dade College
  2. 2. <ul><li>“ I will persist until I succeed”. </li></ul><ul><li>Og Mandino </li></ul>
  3. 3. Shoulder
  4. 5. Shoulder <ul><li>1. Glenohumeral Joint: A spheroidal (ball & socket) joint that is the principal articulation of the shoulder </li></ul><ul><ul><li>Inferior Glenohumeral ligament </li></ul></ul><ul><ul><ul><li>A major anterior stabilizer of the glenohumeral joint, especially with the arm abducted </li></ul></ul></ul><ul><ul><li>Middle Glenohumeral ligament </li></ul></ul><ul><ul><ul><li>Prevents anterior instability when the shoulder is externally rotated and abducted 45 degrees </li></ul></ul></ul><ul><ul><li>Superior Glenohumeral ligament </li></ul></ul><ul><ul><ul><li>Works with the coracohumeral ligament to prevent inferior instability in the adducted arm </li></ul></ul></ul><ul><ul><li>Labrum </li></ul></ul><ul><ul><ul><li>Is a fibrocartilagenous thickening surrounding the glenoid that deepens the glenoid cavity. </li></ul></ul></ul><ul><ul><ul><li>It prevents abnormal motion and serves to anchor the inferior glenohumeral ligament complex </li></ul></ul></ul>
  5. 6. Shoulder <ul><li>2. Sternoclavicular Joint: </li></ul><ul><ul><li>Gliding joint with disc </li></ul></ul><ul><ul><li>anchors shoulder girdle to chest wall (sternum to clavicle) </li></ul></ul><ul><li>3. Acromioclavicular joint: </li></ul><ul><ul><li>Gliding joint with incomplete disc. </li></ul></ul><ul><ul><li>Attaches acromion and clavicle </li></ul></ul><ul><li>4. Scapulothoracic joint: </li></ul><ul><ul><li>Medial border of scapula articulates with posterior aspect of ribs 2-7 </li></ul></ul><ul><ul><li>The ratio of glenohumeral to scapulothoracic motion during shoulder abduction is 2:1 </li></ul></ul>
  6. 7. Shoulder <ul><li>5. Supporting structures (from superficial to deep layers) </li></ul><ul><ul><li>A. deltoid, pectoralis major </li></ul></ul><ul><ul><li>B. clavicopectoral fascia, conjoined tendon, pectoralis minor </li></ul></ul><ul><ul><li>C. subdeltoid bursa, rotator cuff muscles </li></ul></ul><ul><ul><li>D. glenohumeral capsule, coracohumeral ligament </li></ul></ul>
  7. 8. Finding Significance <ul><ul><li>Muscle wasting Chronic rotator cuff tear, nerve injury </li></ul></ul><ul><ul><li>“ Popeye” muscle Proximal rupture of long head of biceps </li></ul></ul><ul><ul><li>Scapular winging Serratus anterior (long thoracic nerve) injury </li></ul></ul><ul><ul><li>Superior prominence Acromioclavicular </li></ul></ul><ul><ul><li>(piano key sign) separation/ clavical fracture </li></ul></ul><ul><ul><li>Anterior prominence Glenohumeral dislocation, sternoclavicular injury </li></ul></ul><ul><ul><li>Systemic hyperlaxity Multidirectional instability </li></ul></ul>
  8. 9. Exam Technique Significance <ul><li>Impingement sign passive forward flexion pain = >90 degrees impingement syndrome </li></ul><ul><li>Impingement Test same after subacromial relief of pain= </li></ul><ul><li>lidocaine impingement syndrome </li></ul><ul><li>Hawkins Test passive forward flex to pain= impingement synd (Dump out can) 90 & internal rotation </li></ul><ul><li>Apprehension Test Abduction to 90 & + appreh test= ant. </li></ul><ul><li>external rotation shoulder instability </li></ul><ul><li>Sulcus sign downward traction sulcus below on arm acromion=inferior laxity </li></ul>
  9. 10. Exam Technique Significance <ul><li>Crossed Chest, Passive forward flex pain= AC pathology </li></ul><ul><li>Adduction test to 90 & adduction </li></ul><ul><li>Acromioclavicular same after AC lido inj relief of pain= AC path </li></ul><ul><li>Injection </li></ul><ul><li>Yergason test resisted supination pain= bicipital tendonitis </li></ul><ul><li>Lift off sign arm behind back lifted inability to accomplish </li></ul><ul><li>posteriorly = subscapularis tear </li></ul><ul><li>Wrights test extension, abduction, loss of pulse, </li></ul><ul><li> external rotation of arm, reproduction of symp </li></ul><ul><li> neck rotated away = thoracic outlet synd </li></ul>
  10. 16. Anterior Glenohumeral Dislocation “Shoulder dislocation” <ul><li>Mechanism of injury: </li></ul><ul><ul><li>From external rotation or abduction force on humerus </li></ul></ul><ul><ul><li>From a direct posterior blow to proximal humerus </li></ul></ul><ul><ul><li>From a posterolateral blow on the shoulder </li></ul></ul><ul><li>Exam: </li></ul><ul><ul><li>Space underneath acromion where humeral head should lie </li></ul></ul><ul><ul><li>Palpable anterior mass representing humeral head in anterior axilla </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Closed reduction </li></ul></ul><ul><ul><li>Immobilization in internal rotation </li></ul></ul>
  11. 17. Types of closed reduction <ul><li>Stimson maneuver: </li></ul><ul><ul><li>Pt prone on table with weight on arm </li></ul></ul><ul><li>Mitch maneuver: </li></ul><ul><ul><li>Pt supine, steady downward traction applied at elbow, combined with slow gradual external rotation and abduction of limb </li></ul></ul><ul><li>Hippocratic maneuver: </li></ul><ul><ul><li>Pt supine, examiner places sole of foot in axilla (shoe removed), grabs pt’s wrist with both hands and applies steady longitudinal traction </li></ul></ul><ul><li>Traction/ countertraction: </li></ul><ul><ul><li>Sheet method 2 people opposing </li></ul></ul><ul><li>Scapular manipulation </li></ul><ul><ul><li>Stimson maneuver with medial manipulation of tip of scapula </li></ul></ul>
  12. 18. Anterior Glenohumeral Dislocation <ul><li>2 lesions with recurrent dislocations: </li></ul><ul><ul><li>Bankhart Lesion: </li></ul></ul><ul><ul><ul><li>Anterior capsular injury assoc with a tear of the glenoid labrum off the anterior glenoid rim </li></ul></ul></ul><ul><ul><li>Hill-Sachs Lesion: </li></ul></ul><ul><ul><ul><li>Compression fracture of the articular surface of the humeral head posterolaterlaterally that is created by the sharp edge of the anterior glenoid as the humeral head dislocates over it </li></ul></ul></ul>
  13. 20. Glenoid Labrum Injury <ul><li>From repeated anterior subluxation of the shoulder </li></ul><ul><li>From anterior instability during acceleration phase of throwing secondary to long head of biceps pulling on anterior labrum </li></ul><ul><li>From repetitive bench pressing and overhead pressing </li></ul><ul><li>From fall on outstretched arm </li></ul>
  14. 21. Glenoid Labrum Injury <ul><li>Patient c/o pain that interrupts smooth functioning of shoulder during performance of specific activity </li></ul><ul><li>Exam: </li></ul><ul><ul><li>Pain on forced external rotation @ 90 degrees abduction </li></ul></ul><ul><ul><li>“ pop” or “click” on forced external rotation </li></ul></ul><ul><ul><li>Weakness of rotator cuff muscles </li></ul></ul><ul><li>CT scan or MRI with contrast may allow early detection </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Physical therapy </li></ul></ul><ul><ul><li>Arthroscopic repair </li></ul></ul>
  15. 24. Rotator Cuff <ul><li>The rotator cuff connects the humerus to the scapula. </li></ul><ul><li>The rotator cuff is formed by the tendons of four muscles: </li></ul><ul><ul><li>the supraspinatus, </li></ul></ul><ul><ul><li>infraspinatus, </li></ul></ul><ul><ul><li>teres minor, and </li></ul></ul><ul><ul><li>subscapularis. </li></ul></ul>
  16. 26. <ul><li>Bursitis </li></ul>
  17. 27. Bursitis <ul><li>Bursitis is defined as inflammation of a bursa. </li></ul><ul><li>Bursae are closed, round, flattened sacs that are lined by synovium and separate bare areas of bone from overlapping muscles (deep bursae) or skin and tendons (superficial bursae). </li></ul><ul><li>They occur at areas of friction or possible impingement. </li></ul><ul><li>Bursae function to reduce friction and allow a greater range of movement when muscle contracts. </li></ul><ul><li>They may or may not communicate with the adjacent joint space. Symptoms of bursitis include inflammation, localized tenderness, warmth, edema, erythema of the skin (if superficial), and loss of function </li></ul><ul><li>When inflamed, the synovial cells increase in thickness and may show villous hyperplasia. </li></ul><ul><li>Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue formation. </li></ul><ul><li>The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage sometimes occurs. </li></ul><ul><li>Patients often complain of a dull shoulder ache. </li></ul><ul><li>The most common symptom of subacromial bursitis is tenderness over the greater trochanter (and beneath the deltoid muscle) that disappears when the arm is abducted. </li></ul>
  18. 28. Clavicle fracture <ul><li>Most common bone fractured </li></ul><ul><li>The weakest part being the junction of the middle and lateral thirds </li></ul><ul><li>Class A (middle third fractures) (80%): </li></ul><ul><ul><li>Treat with sling immobilization. </li></ul></ul><ul><ul><li>Some prefer using a figure-eight clavicular splint, especially for displaced fractures. </li></ul></ul><ul><li>Class B (distal third fractures) (15%): </li></ul><ul><ul><li>Treat type I (nondisplaced) and type III (articular surface) fractures with sling immobilization. </li></ul></ul><ul><ul><li>Immobilize type II (displaced) fractures in a sling and swathe. </li></ul></ul><ul><ul><li>These may require orthopedic surgical fixation. </li></ul></ul><ul><li>Class C (proximal third) (5%): </li></ul><ul><ul><li>Treat nondisplaced fractures with sling immobilization. </li></ul></ul><ul><ul><li>Displaced injuries may require orthopedic referral for surgical reduction. </li></ul></ul><ul><ul><li>Neonatal fractures generally heal spontaneously in several weeks without special treatment. </li></ul></ul>
  19. 29. Normal-----  <ul><li>  ----- Normal </li></ul><ul><li>FRACTURE ----  </li></ul>
  20. 30. Acromio-clavicular (AC) separation (separated shoulder) <ul><li>Mechanism of injury- fall onto point of shoulder </li></ul><ul><li>If there has been significant disruption (or a fracture to the clavicle itself), the area will appear swollen and deformed compared with the other side. </li></ul><ul><li>The patient will avoid movement, do to pain. </li></ul><ul><li>Gently have the patient move their arm across their chest while you palpate in the AC region. </li></ul><ul><ul><li>This will cause pain specifically at the AC joint if there is separation. </li></ul></ul><ul><li>Tenderness is felt at the junction, or the site of the AC (acromioclavicular) joint . </li></ul>
  21. 40. Paralysis of the Serratus Anterior <ul><li>Results from injury to the long thoracic nerve causing a “Winging of the Scapula” </li></ul>
  22. 41. ITALY <ul><li>TREVI FOUNTAIN ROMA </li></ul><ul><li>FONTANA DI TREVI </li></ul>
  23. 43. Brachial Plexus Injuries <ul><li>Disease, stretching, and wounds in the posterior triangle of the neck </li></ul><ul><li>Injuries to the brachial plexus result in paralysis and anesthesia. </li></ul><ul><li>Superior trunk injuries (C5-6): “Waiter’s tip ” position (Erb-Duchenne palsy) </li></ul><ul><ul><li>Fall (motorcycle), newborn forced delivery (stretched neck), heavy backpacks </li></ul></ul><ul><li>Inferior injuries (C8-T1 ): “Claw hand” (Klumpke paralysis) </li></ul><ul><ul><li>Arm jerked superiorly, grabbing tree branch while falling, pulling on baby’s upper ext during childbirth. </li></ul></ul>
  24. 49. Bicipital Tendonitis <ul><li>Pain localized to proximal humerus and shoulder joint, with resistive supination of the forearm aggravating symptoms </li></ul><ul><li>+ Yergason test (resisted supination) for unstable long head of biceps in bicipital groove </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Physical therapy </li></ul></ul><ul><ul><li>Activity modification </li></ul></ul><ul><ul><li>NSAID’s </li></ul></ul>
  25. 52. Shoulder Fractures <ul><li>Proximal Humerus Fractures: </li></ul><ul><ul><li>Neer classificaton: </li></ul></ul><ul><ul><ul><li>Non-displaced fractures: </li></ul></ul></ul><ul><ul><ul><ul><li>are displaced less than 1cm or angulated <45 degrees, regardless of the fracture pattern or # of fragments </li></ul></ul></ul></ul><ul><ul><ul><li>Displaced fractures: </li></ul></ul></ul><ul><ul><ul><ul><li>2 part fx’s are fractured either through the anatomical neck, surgical neck, greater tuberosity or lesser tuberosity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>3 part fx’s are fx’s of the surgical neck with fractures of either the greater tuberosity or lesser tuberosity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>4 part fx’s are fxs of the anatomic neck & fractures of the greater and lesser tuberosities </li></ul></ul></ul></ul>
  26. 54. Humeral Fractures <ul><li>Neurovascular status must be evaluated with fractures </li></ul><ul><li>The humerus is in direct contact with nerves that can be injured due to a fracture. </li></ul><ul><ul><li>Surgical neck : axillary nerve (C5-6, deltoid atrophy) (also from improper crutch use “waiter’s tip”) </li></ul></ul><ul><ul><li>Radial groove: radial nerve </li></ul></ul><ul><ul><li>Distal end of humerus : median nerve </li></ul></ul><ul><ul><li>Medial epicondyle: ulnar nerve </li></ul></ul>
  27. 56. Proximal Humerus Fracture <ul><li>The vascularity is at risk with anatomical neck fractures </li></ul><ul><li>Most common mechanism of injury= FOOSH </li></ul><ul><li>Signs & symptoms: </li></ul><ul><ul><li>Pain, swelling, tenderness </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>For nondisplaced fx’s= sling, begin ROM exercises </li></ul></ul><ul><ul><li>2 part/3 part fx’s= closed reduction, sling, possible ORIF </li></ul></ul><ul><ul><li>Absolute indication for hemi-arthroplasty: 4 part fx’s, non-reducible 3 part fx’s </li></ul></ul><ul><ul><li>FOOSH = Fall On Outstretched Hand </li></ul></ul>
  28. 57. Midshaft Humerus Fractures <ul><li>Signs & Symptoms: </li></ul><ul><ul><li>Arm pain, swelling, deformity </li></ul></ul><ul><ul><li>The arm is shortened with gross motion & crepitus on gentle manipulation </li></ul></ul><ul><li>XR: </li></ul><ul><ul><li>AP/lat c shoulder & elbow </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Coaptation splint </li></ul></ul><ul><ul><ul><li>Carefully molded plaster slab placed around medial & lateral aspects of arm, extending from axilla around elbow & over deltoid & acromion x 2 wks </li></ul></ul></ul><ul><ul><li>Change to Sarmiento brace @ 2 wks </li></ul></ul><ul><ul><li>May require ORIF with plate/screw or intramedullary nailing </li></ul></ul>
  29. 58. Midshaft humerus fx
  30. 59. Distal Humerus Fracture <ul><li>Supracondylar fx’s of the Humerus: </li></ul><ul><ul><li>Characterized by dissociation b/t diaphysis & condyles of distal humerus, frequently extended distally & involves articular surface </li></ul></ul><ul><ul><li>Caused by FOOSH or direct blow </li></ul></ul><ul><ul><li>PE: </li></ul></ul><ul><ul><ul><li>+ deformity, instability, crepitus </li></ul></ul></ul><ul><ul><li>XR: </li></ul></ul><ul><ul><ul><li>AP/lat/obliq </li></ul></ul></ul><ul><ul><li>Management: </li></ul></ul><ul><ul><ul><li>Initial: alignment, immobilization, ice, long arm splint </li></ul></ul></ul><ul><ul><ul><li>Definitive: ORIF, early motion </li></ul></ul></ul><ul><li>(Other fx’s: transcondylar, medial condyle, lateral condyle) </li></ul>
  31. 61. MONTMARTRE <ul><li>PARIS </li></ul><ul><li>FRANCE </li></ul>
  32. 65. Radial Head Fracture <ul><li>MOI: </li></ul><ul><ul><li>Fall forward with elbow extended, forearm pronated </li></ul></ul><ul><li>Pain localized to radial head </li></ul><ul><li>XR: </li></ul><ul><ul><li>AP/lat/obliq </li></ul></ul><ul><li>TX: </li></ul><ul><ul><li>Types I, II, & III without mechanical block are treated with a sling and AROM x 3 wks </li></ul></ul><ul><ul><li>After 3 wks d/c sling & begin aggressive PT </li></ul></ul><ul><ul><li>Fx’s with elbow instability or mechanical block are treated operatively with either reduction & fixation of head, excision of head, or ligament repair </li></ul></ul>
  33. 67. Olecranon Fractures <ul><li>Pain @ elbow with h/o trauma </li></ul><ul><li>XR: </li></ul><ul><ul><li>AP/lat/obliq </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>Initial: sling for comfort </li></ul></ul><ul><ul><li>Definitive: </li></ul></ul><ul><ul><ul><li>non-displaced fx’s can be managed with posterior splint @ 90 degrees flexion x 2 wks </li></ul></ul></ul><ul><ul><ul><li>Other fx’s are managed with ORIF or percutaneous pinning & early motion post-operatively </li></ul></ul></ul>
  34. 71. Nursemaid’s Elbow <ul><li>Subluxation of the radial head from the Annular ligament </li></ul><ul><li>MC from sudden jerking of child’s hand while in pronation </li></ul>
  35. 75. Elbow Fractures <ul><li>Monteggia Fracture </li></ul><ul><ul><li>Usually a fx of the mid or proximal ulna with anterior dislocation of the radial head </li></ul></ul><ul><ul><li>MOI: </li></ul></ul><ul><ul><ul><li>Forceful pronation or direct blow to dorsum of ulna </li></ul></ul></ul><ul><ul><li>H&P: </li></ul></ul><ul><ul><ul><li>Pain & h/o trauma, may have obvious deformity </li></ul></ul></ul><ul><ul><li>XR: </li></ul></ul><ul><ul><ul><li>AP/lat/obliq </li></ul></ul></ul><ul><ul><li>TX: </li></ul></ul><ul><ul><ul><li>Hematoma block, reduction, long arm cast or splint </li></ul></ul></ul><ul><ul><ul><li>May require ORIF </li></ul></ul></ul>
  36. 77. Galeazzi Fracture/dislocation <ul><li>An injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ), which disrupts the forearm axis joint. </li></ul><ul><li>&quot;fracture of necessity&quot; refers to the adult Galeazzi fracture not being amenable to treatment by closed means, necessitating surgical stabilization. </li></ul>
  37. 78. Galeazzi (Reverse Monteggia)
  38. 79. <ul><li>SAN CARLOS DE BARILOCHE </li></ul><ul><li>ARGENTINA </li></ul>
  39. 86. Lateral Epicondylitis (Tennis Elbow) <ul><li>Pain at lateral humeral epicondyle, reproduced by extending the wrist against resistance </li></ul><ul><li>Seen in patients who perform repetitive wrist extension (Tennis) </li></ul><ul><li>Tx: </li></ul><ul><ul><li>NSAID’s, Restriction band, Physical therapy, lighter racquet, correction of backhand stroke </li></ul></ul>
  40. 88. Medial Epicondylitis (Pitcher’s Elbow, Golfer’s) <ul><li>Pain at medial humeral epicondyle </li></ul><ul><li>Seen in patients who golf, or perform throwing sports, such as baseball, football, javelin </li></ul><ul><li>Tx: </li></ul><ul><ul><li>NSAID’s, Physical therapy </li></ul></ul>
  41. 92. Movements at the wrist <ul><li>Radial deviation (abduction) </li></ul><ul><li>Ulnar deviation (adduction) </li></ul><ul><li>Flexion </li></ul><ul><li>Extension </li></ul><ul><li>Supination </li></ul><ul><li>Pronation </li></ul><ul><li>Combination of all of the above </li></ul>
  42. 96. Distal Forearm Fractures <ul><li>1. Extension fractures: </li></ul><ul><li>Colles Fracture </li></ul><ul><ul><li>Extra-articular fx with dorsal displacement of distal radius </li></ul></ul><ul><ul><li>MC fx of the wrist </li></ul></ul><ul><ul><li>Usually 2° to FOOSH </li></ul></ul><ul><ul><li>Exam: </li></ul></ul><ul><ul><ul><li>Silver fork deformity , swelling, decreased ROM secondary to pain </li></ul></ul></ul><ul><ul><li>XR: </li></ul></ul><ul><ul><ul><li>AP/true lateral/obliq- radius will be shortened </li></ul></ul></ul>
  43. 97. Colles fx
  44. 98. Distal Forearm Fractures (cont) <ul><li>2. Non-displaced Distal Radius Fx’s </li></ul><ul><ul><li>Require short arm cast (SAC) in neutral, ice, elevation, NSAIDS, analgesia </li></ul></ul><ul><li>3. Other common fx’s: </li></ul><ul><ul><li>Smith’s fx </li></ul></ul><ul><ul><ul><li>Reverse Colles fx </li></ul></ul></ul><ul><ul><ul><li>Fracture of the distal radius with palmar displacement of the distal fragment. </li></ul></ul></ul><ul><ul><li>Die Punch Fx </li></ul></ul><ul><ul><ul><li>Intra-articular distal radius fx with impaction of the dorsal aspect of the lunate fossa </li></ul></ul></ul><ul><ul><li>Barton’s Fx </li></ul></ul><ul><ul><ul><li>Displaced intra-articular lip fx of the distal radius </li></ul></ul></ul><ul><ul><ul><li>May be assoc with carpal subluxation </li></ul></ul></ul><ul><ul><ul><li>May be dorsal or volar configuration </li></ul></ul></ul><ul><ul><ul><li>Extends into radio-carpal joint </li></ul></ul></ul>
  45. 99. Non-displaced distal radius fx
  46. 100. Smith’s fx
  47. 101. Die Punch Fx
  48. 102. Barton’s Fx
  49. 103. ROSETTE OF NOTRE DOME <ul><li>PARIS </li></ul><ul><li>FRANCE </li></ul>
  50. 104. Scaphoid Fractures <ul><li>MC fx’d carpal bone </li></ul><ul><li>There is no direct blood supply to the proximal portion of the scaphoid </li></ul><ul><li>Therefore, scaphoid fx’s have a tendency to develop delayed union or avascular necrosis </li></ul><ul><li>Remember the more proximal the fx line is in the scaphoid injuries, the greater the likelyhood of avascular necrosis </li></ul><ul><li>Mechanism of injury </li></ul><ul><ul><li>Forceful hyperextension of the wrist </li></ul></ul>
  51. 105. Scaphoid Fractures <ul><li>Exam: </li></ul><ul><ul><li>+ snuffbox tenderness , </li></ul></ul><ul><ul><li>radial deviation of wrist will probably elicit pain </li></ul></ul><ul><li>XR: </li></ul><ul><ul><li>Obtain AP/lat/obliq/scaphoid views </li></ul></ul><ul><ul><li>Plain x-ray may not demonstrate fx for up to 4 wks </li></ul></ul><ul><ul><li>If x-rays are still negative at 10-14 days & pt is symptomatic, obtain bone scan for definitive diagnosis </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Initially in ER: </li></ul></ul><ul><ul><ul><li>Thumb spica (*always tx snuffbox tenderness, even if x-ray neg) </li></ul></ul></ul><ul><ul><li>Definitive: </li></ul></ul><ul><ul><ul><li>Long arm thumb spica cast x 4-8 wks. </li></ul></ul></ul><ul><ul><ul><li>If scaphoid is displaced, may require ORIF </li></ul></ul></ul>
  52. 109. <ul><li>A. Thumb B. Index C. Middle finger D. Ring finger E. Little finger </li></ul><ul><li>I-V. Metacarpal bones </li></ul><ul><li>1,4. Distal phalanx 2. Middle phalanx 3,5. Proximal phalanx 6. Sesamoid bones 7. Distal interphalangeal joint (DIP) 8. Proximal interphalangeal joint (PIP) 9. Metacarpophalangeal joint (V.) 10. Carpometacarpal joints </li></ul><ul><li>11. Trapezium 12. Trapezoid 13. Capitate 14. Hamate 15. Scaphoid 16. Lunate 17. Triquetrum 18. Pisiform </li></ul><ul><li>19. Radius 20. Ulna </li></ul>
  53. 110. Metacarpal Neck Fractures <ul><li>Boxer’s fx : Most frequently occur at the 5 th metacarpal, as a result of a direct blow delivered to the hand or by the hand to a solid (animate or inanimate) object while the hand is held in a fist </li></ul>
  54. 111. Metacarpal Neck Fx’s (Boxer’s fx) <ul><li>Fractures with angulation <15 degrees should be immobilized in an ulnar gutter splint encasing both the 4 th & 5 th fingers with the mcp joint flexed as close to 90 degrees as possible & wrist held in slight extension </li></ul><ul><li>Fx’s with angulation >15 degrees &/or with rotational deformity of the finger should be reduced & casted/splinted in the aforementioned position </li></ul><ul><li>Post reduction films should be obtained </li></ul><ul><li>Unstable fx’s or fx’s that are not reduced to an acceptable position may require percutaneous pinning </li></ul>
  55. 116. Boutonniere Deformity <ul><li>Disruption of the central slip of the Extensor Digitorum Communis tendon from its insertion at the dorsal base of the middle phalanx that results in </li></ul><ul><li>a flexed PIP joint & hyperextended DIP joint </li></ul><ul><li>The deformity may not be present at the time of injury & usually develops over 10-21 days </li></ul><ul><li>Tx: </li></ul><ul><ul><li>1. Splint PIP joint into full extension with passive & active flexion of DIP joint </li></ul></ul><ul><ul><li>2. Insert K-wire to PIP joint to hold extension, </li></ul></ul><ul><ul><li>3. continue passive & active flexion at DIP joint </li></ul></ul><ul><ul><li>4. direct tendon repair & splinting </li></ul></ul>
  56. 118. Mallet Finger <ul><li>Disruption of the extensor tendon over the distal phalanx with flexion at the DIP joint & extension or hyperextension at the PIP joint </li></ul><ul><li>Tx: </li></ul><ul><ul><li>1. splint with hyperextension of the DIP joint, flexion of the PIP joint </li></ul></ul><ul><ul><li>2. Hold with K-wire </li></ul></ul><ul><ul><li>3. Direct tendon repair & splinting </li></ul></ul>
  57. 123. Flexor Tenosynovitis <ul><li>Infection of the digital synovial sheaths. </li></ul><ul><li>Usually confined to affected finger </li></ul><ul><ul><li>Except in pinky and thumb , can spread to palm, and forearm </li></ul></ul><ul><li>Diagnosis is made on four classic findings . </li></ul><ul><ul><li>1. tenderness over flexor tendon sheath </li></ul></ul><ul><ul><li>2. symmetric swelling of the finger (sausage finger) </li></ul></ul><ul><ul><li>3. pain with passive extension </li></ul></ul><ul><ul><li>4. flexed posture of the involved digit at rest </li></ul></ul>
  58. 124. Trigger finger <ul><li>Trigger finger is a painful condition caused by a narrowing of the sheath that surrounds the finger tendon. </li></ul><ul><li>Inflammation due to overuse is usually the cause. </li></ul><ul><li>Tendons slide through a snug tunnel . </li></ul><ul><li>Irritation as the tendons slip into the tunnel can cause the opening of the tunnel to become smaller, or the tendon to thicken so that it can't easily pass through the tunnel. </li></ul><ul><li>As you try to straighten the finger, the tendon becomes momentarily stuck at the mouth of the tunnel then pops as the tendon slips past the tight area. </li></ul><ul><li>No X-rays or other testing are usually needed </li></ul><ul><li>Tx: </li></ul><ul><ul><li>NSAID’s, splint, cortisol injection, surgical release </li></ul></ul>
  59. 130. Game Keeper’s Thumb Skier’s Thumb <ul><li>Injury to the ulnar collateral ligament of the MCP joint of the thumb </li></ul><ul><li>Destroys joint stability </li></ul><ul><li>Impairs ability to pinch </li></ul><ul><li>Evaluation: </li></ul><ul><li>Stress ulnar aspect of the MCP joint by forcing thumb into radial abduction </li></ul><ul><ul><li>If there is <15 degrees of side to side difference (one thumb compared to the other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical repair is required </li></ul></ul><ul><ul><li>Closed tx with a thumb spica cast or splint with the thumb slightly adducted may allow for healing of an incomplete tear </li></ul></ul>
  60. 131. Game Keeper’s Thumb (occupation, over period of time) <ul><li>Skier’s Thumb </li></ul><ul><li>(sport, acutely) </li></ul>
  61. 132. De Quervain’s Tenosynovitis <ul><li>The disease is an entrapment tendonitis of the tendons contained within the first dorsal compartment at the wrist, resulting in pain with thumb motion. </li></ul><ul><li>The most classic finding in de Quervain tenosynovitis is a positive Finkelstein test . </li></ul><ul><ul><li>Perform the Finkelstein test by having the patient make a fist with the thumb inside the fingers. </li></ul></ul><ul><ul><li>The clinician then applies passive ulnar deviation of the wrist to reproduce the chief complaint of dorsolateral wrist pain. </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Splinting of the thumb and wrist relieves symptoms (although noncompliance rates are high) </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Corticosteroid injection </li></ul></ul><ul><ul><li>Surgical release </li></ul></ul>
  62. 133. <ul><li>Positive </li></ul><ul><li>Finkelstein test . </li></ul>
  63. 135. Paronychia <ul><li>A paronychia is a superficial infection of epithelium lateral to the nail plate . </li></ul><ul><li>The acute painful purulent infection is most frequently caused by staphylococci. </li></ul><ul><li>The patient's condition and discomfort are markedly improved by a simple drainage procedure </li></ul>
  64. 136. Felon <ul><li>Felons are closed-space infections of the fingertip pulp . </li></ul><ul><li>Fingertip pulp is divided into numerous small compartments by vertical septa that stabilize the pad. </li></ul><ul><li>Infection occurring within these compartments can lead to abscess formation, edema, and rapid development of increased pressure in a closed space. </li></ul><ul><li>This increased pressure may compromise blood flow and lead to necrosis of the skin and pulp. </li></ul>
  65. 137. Herpetic Whitlow <ul><li>Herpes simplex virus may cause an intense, painful skin infection. </li></ul><ul><li>The fingertip is sore and swollen but is not as firm as in a felon. </li></ul><ul><li>The appearance of tiny fluid-filled blebs (vesicles) on the fingers is diagnostic . </li></ul><ul><li>A herpetic whitlow is often mistaken for a felon. </li></ul><ul><li>The disorder eventually goes away on its own. </li></ul><ul><li>Surgery is not needed. </li></ul>
  66. 138. INFECTIONS CAUSED BY BITES <ul><li>The most common cause is injury to the knuckles by the teeth from a punch to the mouth. </li></ul><ul><li>Animal bites are also common causes. </li></ul><ul><li>Wound contamination by a number of types of bacteria can result from human and animal bites. </li></ul><ul><li>All bite injuries are potentially dangerous and can cause significant infection. </li></ul><ul><li>The injured area should be cleaned surgically, with the wound left open. </li></ul><ul><li>Antibiotics should be given to prevent joint infection (septic arthritis), which can otherwise lead to permanent destruction of the knuckle joints. </li></ul><ul><li>Bacteria in human and animal bites are resistant to many antibiotics but are generally sensitive to </li></ul><ul><li>ampicillin and penicillin. </li></ul><ul><li>(in practice use: augmentin) </li></ul>
  67. 142. The Hand <ul><li>Nerves: </li></ul><ul><ul><li>Radial : </li></ul></ul><ul><ul><ul><li>Provides sensation to dorsum of hand on radial side of third metacarpal & dorsal thmb, index, & middle fingers as far as the distal phalanges. </li></ul></ul></ul><ul><ul><ul><li>The first web space is the most ‘pure’ area to test radial nerve sensation. </li></ul></ul></ul><ul><ul><ul><li>Motor= test thumb extension- hitchiking </li></ul></ul></ul><ul><ul><li>Ulnar : </li></ul></ul><ul><ul><ul><li>Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little fingers. </li></ul></ul></ul><ul><ul><ul><li>The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve sensation </li></ul></ul></ul><ul><ul><ul><li>Motor= test opposition (little finger), finger adduction </li></ul></ul></ul><ul><ul><li>Median : </li></ul></ul><ul><ul><ul><li>Provides sensation to palm & palmar surface of thumb, index, middle, & half of ring finger; may supply dorsum of terminal phalanges of these fingers </li></ul></ul></ul><ul><ul><ul><li>The distal palmer aspect of the index finger is the most ‘pure’ area to test median nerve sensation </li></ul></ul></ul><ul><ul><ul><li>Motor= test opposition (thumb) </li></ul></ul></ul>
  68. 144. UE Arteries & Nerves <ul><li>Crutch misuse </li></ul><ul><li>Thoracic Outlet Obstruction </li></ul><ul><li>Carpal Tunnel </li></ul><ul><li>Cubital Tunnel </li></ul><ul><li>Saturday Night Palsy </li></ul>
  69. 145. Thoracic Outlet Syndrome <ul><li>Usually resulting from irritation of C8 and T1 innervated nerves, </li></ul><ul><li>may be caused by </li></ul><ul><ul><li>a cervical rib, </li></ul></ul><ul><ul><li>a fiber spanning from a rudimentary cervical rib, </li></ul></ul><ul><ul><li>tendinous bands from the scalenus anterior to the medius muscles or </li></ul></ul><ul><ul><li>hypertrophic clavicle fracture callus </li></ul></ul><ul><li>Neurologic, venous, or arterial symptoms </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Postural exercises </li></ul></ul><ul><ul><li>Surgical resection of cervical rib, first rib, or scalenotomy </li></ul></ul>
  70. 150. Carpal Tunnel <ul><li>The syndrome is characterized by pain, paresthesias, and weakness in the median nerve distribution of the hand. </li></ul><ul><li>Trauma vs. repetitive motion </li></ul><ul><li>Acute CTS can be thought of as a compartment syndrome of the carpal canal, and decompression should be performed as soon as possible </li></ul><ul><li>Tinel’s and Phalen’s tests , nerve conduction studies </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Steroid inj, splinting, NSAID’s, surgical release </li></ul></ul>
  71. 152. Cubital Tunnel Syndrome <ul><li>is the effect of pressure on the “funny bone” causing pain, paresthesia’s to the ulnar nerve distribution </li></ul>
  72. 154. Saturday Night Palsy <ul><li>The patient has injured his upper arm, usually by sleeping with his arm over the back of a chair, and now presents holding the affected hand and wrist with his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, thumb and finger joints. </li></ul><ul><li>With the hand supinated (palm up) and the extensors aided by gravity, hand function may appear normal, but when the hand is pronated (palm down) the wrist and hand will drop. </li></ul>
  73. 160. Enlargement of the Lymph Nodes (Lymphadenopathy) <ul><li>Infection (streaking) </li></ul><ul><ul><li>Lymphangitis: inflammation of the lymph vessels. </li></ul></ul><ul><li>Breast Ca (sentinel node) </li></ul><ul><ul><li>Lymphedema </li></ul></ul>
  74. 161. 'Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.' Aristoteles <ul><li>A journey of a thousand miles begins with a single step. </li></ul><ul><li>Lao Tsu </li></ul><ul><li>“ I find that the harder I work, the more luck I seem to have”. </li></ul><ul><li>  Thomas Jefferson </li></ul><ul><li>Self conquest is the greatest of victories. </li></ul><ul><li>Plato </li></ul><ul><li>“ Imagination is everything. It is the preview of life’s coming </li></ul><ul><li>attractions.” </li></ul><ul><li>Albert Einstein </li></ul><ul><li>Nothing great was ever achieved without enthusiasm. </li></ul><ul><li>Ralph Waldo Emerson </li></ul><ul><li>“ If a man empties his purse into his head, no man can take it </li></ul><ul><li>away from him. An investment in knowledge always pays the best </li></ul><ul><li>interest” Benjamin Franklin </li></ul>