Cram The Pance - S1E45 MSK Upper Extremity

Episode Date: April 19, 2022

MSK Upper Extremity review for your Pance, Panre, and Eor's. ►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)Included in review: Anterior Glenohumeral Dislocation, Posterior Glenohumeral Dislocation, Rotator Cuff Injuries, Rotator Cuff Tear, Adhesive Capsulitis/ Frozen Shoulder, Supracondylar Humerus Fractures, Radial Head Fractures, Ulnar Shaft (Nightstick) Fracture, Monteggia & Galeazzi Fractures, Radial Head Subluxation / Nursemaid Elbow, Medial Epicondylitis, Lateral Epicondylitis, Cubital Tunnel Syndrome / Ulnar Neuropathy, Carpal Tunnel Syndrome, Scaphoid (Navicular) Fracture, Distal Radius Fractures (Colles vs. Smith Fracture), Lunate Fractures, de Quervain Tendinopathy, Mallet Finger, Ulnar collateral ligament injury (Gamekeeper's or Skier's thumb), Boxers Fracture, Complex Regional Pain Syndrome.Become a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

Okay, so let's do a cram session for MSK upper extremity. As always, I'm going to stick to the need to know stuff. I'm not going to bother your time with the stuff that I really feel is very low yield and that you don't need to know. So let's go ahead and get started. As always, thank you so much for the really nice comments. You guys are just the nicest people. So thank you so much.

Let's go ahead and start with the shoulder and I'll work our way down. So interior glenohumeral dislocation. So this is your most common type interior dislocation is going to account for around 95 to 97% of cases of shoulder dislocations. Now as far as the mechanism of injury, it's going to be a blow to the abducted, externally rotated, and extended arm. So that's the most common mechanism of injury. So think like blocking a basketball shot your arms up and out. Less commonly is going to be a blow to the posterior humorous or a fall on an outstretched arm can also cause an anterior dislocation. But focus on that arm being abducted, abducted, away from the body, extended and externally

rotated and then something hitting the arm in that position. Now in physical exam, you need to know that you're looking for an abducted, abducted, externally rotated arm. So an anterior dislocation of the shoulder causing the arm to be slightly abducted and externally rotated. Diagnosis, you're going to do an x-ray. X-ray of the shoulder is normally going to be enough to diagnose. You're going to get an AP view, scapular y view, axillary view. Few associated injuries you should know with an interior dislocation. There's the Hillsacks, Bankard legions, axillary nerve injury.

I wouldn't go crazy memorizing the specific injury. what they involve. Just know they're associated with anterior dislocation. Hill Sacks, real quick, it's a cortical depression. Hill Sacks lesion is a cortical depression in the humoral head made by the glenoid rim. Bankar lesions occur when the glenoid labrum is disrupted during the dislocation and a bone fragment is evulsed. And then axillary nerve injury, this one's probably the most important associated injury to know. So it's really important to assess the neurovascular status in patients with an anterior shoulder dislocation because axillary nerve dysfunction can actually show up to up to 42% of patients with an anterior dislocation. So you're going to look for a loss of sensation

on what's called the shoulder bands distribution. It's basically like on a cop uniform or a military uniform. Just think of the area of the arm that the shoulder badge would be where they have a badge on the arm. That's where the axillary nerve innervates and that's where they may have this loss of sensation. They may also have deltoid muscle weakness. So just be familiar that axillary nerve dysfunction is common in anterior dislocations. Now as far as treatment, reduce insulin. There's not much to know here. Certainly nothing to memorize. You reduce the dislocation, immobilize it with the sling, and then assess for axillary nerve dysfunction pre-and-post reduction.

Okay, so there's a lot of random things to know for interior dislocations. So the way that you're going to remember them is by remembering a guy named Antonio. So this is visualization time. This is much easier on the YouTube channel. I have a nice little picture I made in MSPaint, but let's just try to visualize this. So Antonio is this guy, and in one hand, he's holding a picture. And in the other hand, he's holding an axe. The picture that he's holding is a bank on top of a hill, like this nice pretty hill with a sunset in the background, and then there's a bank sitting on top of the hill. That's the picture.

In the other hand, he's holding an axe. Now, he's holding both of these up and out by his sides. His arms are abducted, and they're externally rotated. So Antonio helps you to remember this as an anterior dislocation. Antonio anterior dislocation. The picture that he's holding with a bank on top of a hill helps you remember bankart lesions and hill sac lesions that can come. commonly be seen in anterior dislocations. And then the axe he's holding in his other hands helps you remember axillary nerve dysfunction.

That's the most common in interior dislocations. And then finally the position of his arms, like I said, they're abducted and externally rotated. That helps you remember both the way the arm is usually positioned during the physical exam and during the injury too. So remember, guy named Antonio holding a picture of a bank on top of a hill on one hand, holding an axe and the other. Both arms are abducted and externally rotated.

And that should be all you need to know for interior dislocations for the exam. Moving on to posterior glenohumeral dislocations. So these are much less common compared to anterior. They only occur in around 2 to 4% of patients. Mechanism of injury for anterior dislocations wasn't very high yield, but for posterior dislocations, it is. And it's because it's unique. And if you listen to any of my other content, you always know anytime there's something unique, they're going to ask you questions about it.

So keep that in mind. Mechanism for posterior dislocations is going to be seizure and electric shock. So those are the ones that you need to know. Of course, trauma like a blow to the anterior portion of the shoulder can cause a posterior dislocation. But what you should focus on is violent muscle contractions following a seizure or electrocution because those are the unique components that they like to ask questions about. So seizure or electric shock, remember those for your mechanism of injury and a posterior dislocation. Now, physical exam, opposite of anterior. So for a posterior dislocation, it's going to be adducted and internally rotated.

So usually the patient's going to hold their arm in adductions. and internal rotation and is usually unable to externally rotate. Again, that's different than anterior dislocations, which was abducted, abducted, and externally rotated. Now, diagnosis, you're going to get an x-ray. So you'll do your normal routine shoulder views, AP, Y view, etc. But be aware of the light bulb sign on posterior dislocations because they may ask about this. So on the AP view, the humeral head is going to be internally rotated. And because of this, the tuberosities of the humorous, they're not going to be visible. They're going to be, normally they're project out laterally, but they're not going to be

visible because the humoral head's internally rotated. And because of this, you have to take my word for it, the humoral head kind of takes on the circular appearance, and supposedly it looks like a light bulb. I guess it kind of does. So anyways, if you hear a light bulb sign, be thinking posterior dislocation. Treatment's going to be the same as an interior. You're going to reduce and sling. Okay, so for posterior dislocation, there's a few things that you need to know.

Remember your seizure, seizure and shock can be the mechanism of action, mechanism of injury. Remember, the arm is likely going to be abducted and internally rotated. And remember the light bulb sign. Those are the high-yield things. The way that you remember that is I want you to visualize this warning on a poster board. So on the poster board, there's going to be a picture. And on the poster board, there's going to be a picture of a broken light bulb. There's going to be a finger.

and then there's going to be a picture of a guy being shocked. And it says if you add your finger into a broken light bulb, you'll get shocked. So add and into, if you add your finger into, that helps you remember adducted and internal rotation. So if you add your finger into adducted internal rotation, remember, that's the most common presentation. The broken light bulb, because remember the light bulb sign on x-rays, seen in posterior dislocations, and shocked because remember the unique mechanism of injury, electric shock, and seizure. And then again, this is all on a poster board because that poster board helps remember posterior dislocation. So again, remember a poster board and on the poster board, it says if you add your finger into a broken light bulb, you'll get shocked.

Visualized a poster board with a finger, a plus sign, a broken light bulb and a guy being shocked, and you'll remember everything you need to know for posterior dislocations. All right, moving on to a rotator cuff injury. This is definitely a high-heeled topic. There's a good deal to know for this, and you'll likely get a question on this. So let's go over rotator cuff tears and impingement. So first, you need to know your muscles in the rotator cuff. I'm sure you've all heard of the famous mnemonic SITS, so super spinaidus, infrasinatus,

terris minor, and sub-scapularis. Mechanism of injury for rotator cuff injury is going to be a few different things. So degeneration like chronic degenerative tear, that's usually going to be seen in older patients. Impingement, chronic impingement can also lead to a tear and then overload. So like tension overload and athletes who are continually throwing, like in baseball or jobs with repetitive overhead movement. In general, the cause of rotator cuff tears its multifactorial degeneration impingement overload. They can all contribute. There's not really anything I'd say is super important to memorize.

The high yield things for rotator cuff is going to be the presentation of physical exam tests. So clinical manifestations, there's two things to know here. Overhead pain and pain at night. That's the key. So pain exacerbated by overhead activity. So in the vignette, they're going to describe the patient that's maybe reaching up to the shelf and experiencing pain, brushing their hair and having pain, things like that definitely look out for. The location of the pain is usually going to be over the lateral deltoid, so the anterior lateral portion of the shoulder.

And then they also may describe pain at night, so complaining like when the patient's lying on the shoulder at night, they're experiencing pain. That's the classic presentation to look out for in vignettes, the pain over their lateral deltoid when they're reaching overhead or complaining of pain at night. In real life though, it's possible that they're looking at night. may just develop weakness, decreased range of motion. Other studies even suggest a large portion of rotator cuff tears are actually asymptomatic. But for the exam, pain with overhead activities, pain at night, done. Physical exam. So there's a lot of special maneuvers for the rotator cuff when you're looking for impingement and tears. So three that I feel you should be familiar with that seem to be tested on the most is the Hawkins test, the near test, and the empty can test. Again,

these are for both impingement and tears. So let's start with the Hawken and the near These are both really good tests to test for to assess for impingement. So the Hawkins test, also known as the Hawkins Kennedy impingement test, the patient's going to have their shoulders stabilized and positioned in 90 degrees of elevation. The elbow is going to be bent to 90 degrees. The examiner is going to place internal force on the patient's shoulder and then any reproduction of pain elicited by the internal rotation would be a positive test for impingement. Again, if you need visuals on any of these, check out the YouTube channel. I have a lot of different pictures and things like that that kind of help. So the way that I used to remember this test, the Hawkins test, was if you can visualize, when you were a kid, did you ever call someone a chicken?

You do the little arm flapping thing like wings. Well, that's exactly what this looks like when you're doing the Hawkins test. Their shoulders up, their elbows bent. So when I see Hawkins test, it makes me think of a hawk flapping its wings. And it helps you remember this is the one where it looks like you're flapping your wings like a bird or a hawk with the elbow bent, shoulder elevated, and the examiner applying internal rotation. That's exactly what this looks like. You'll have to take my word for it or check out some pictures of the Hawkins test, but it looks like somebody like flapping their wings like a hawk. So again, remember that in your OSCE keys and things like that.

You'll remember what the Hawkins test looks like and what it involves. So remember Hawkins test, flapping your wing like a hawk. Now let's talk about the near test. So the near test, the shoulder is going to be forcibly flexed and internally rotated. So one hand is going to be placed on the shoulder and the scapular area to keep the shoulder from shrugging. The other hand is going to passively lift the arm all the way up to the ear. The arm is going to be internally rotated with the thumb facing down, and then any reproduction of pain is a positive test for impingement. You may see some variations of this test with the arm in neutral position rather than internal, but most of the time it's going to have internal rotation.

I just remember, near is by the ear because in this test, your arm goes all the way up and the shoulder winds up right next to the ear. So when you see the near test, remember, near is the one by the ear. And then finally, the empty can test, also known as the Job's test. This is a good test to evaluate super spinaidus function. Sometimes it's considered the gold standard test due to how well it isolates the super spinaidus and the way that the arm is positioned. It really isolates it well. So the patient's going to place a straight arm out at about 90 degrees of abduction and 30 degrees

of forward flexion. Then internally rotating the arm completely, the thumb is going to be pointing down. And then the patient then resists the clinician's attempts to depress the. arm. So you're trying to push it down. They're resisting. So again, the patient raises their arm forward. Elbow extended, thumbs down as if emptying a can. Examiner's going to apply pressure to the top of the arm, pushing it down. The patient attempts to resist this. Pain without weakness is going to suggest tendonopathy. Pain with weakness is consistent with the tendon tear. There's a lot of other tests, but in my experience, those are the three that seem to be most often tested on. So definitely

be familiar with those three. Now, treatment, conservative versus surgical repair. There's nothing really specific to know here, treatment is all going to depend on, it's really several factors, like the duration of the symptoms, the type of tear, partial versus full thickness, patient age, activity level, et cetera. That's going to guide the treatment as to whether or not they're going to need surgical repair or if they're better suited for, say, physical therapy. Now, if we're talking about tendonitis, the impingement of the rotator cuff, treatment is primarily going to be physical therapy, nseds, et cetera. You're going to find with most of MSK, treatment is pretty repetitive. It's not very high yield.

That's why I kind of run through them quickly because there's just not much to know from an exam standpoint. So if I'm breezing over it, I'm skipping in some cases, it's just because there's nothing really for you to memorize. If there's something high yield for treatment, I'll definitely make sure to bring it to your attention. All right, so let's move on another area of the shoulder known as adhesive capsulitis, also known as a frozen shoulder. So this is a painful and stiff glenohumeral joint that has lost its distensibility and range of motion. So it's exactly what it sounds like. It's a frozen shoulder. It's hard to move.

Passive and active range of motion are going to be substantive. substantially reduced. Risk factors, diabetes. This is a big one. Remember that frozen shoulder is very common in diabetics. In the vignette, it will very, very likely be a diabetic patient. There's actually a study that showed the incidence of frozen shoulder in patients with longstanding type 1 diabetes had a lifetime prevalence of up to 76%. So diabetic patients, remember that. The other risk factor to know is thyroid disorders, particularly hypothyroidism. They increase the risk for frozen shoulder as much as 2.7 times. And then there's some other causes that you shouldn't memorize, should not memorize, like dyslipidemia, prolonged demobilization, stroke, autoimmune

disease, secondary problem after shoulder injury, focus on diabetes. They got that sticky shoulder from all that extra sugar and thyroid disorders. And then also know that this is very common in women, particularly in the fifth and sixth decades of life. It's actually really rare to see this in patients under 40. So in the vignette, be looking for a female in their 50s or 60s, with diabetes or thyroid disorder. For diagnosis, there's nothing I'd really know here. Frozen shoulder is very much a clinical diagnosis made on the basis of the medical history, the physical exam. Imaging really has very little value except just to rule out your differentials like osteoarthritis and things like that.

Treatment is also pretty low yield. Most cases, frozen shoulders is self-limited condition. Physical therapy is the most commonly employed treatment option. Glucocorticoid injections and Seds, other supportive measures, but nothing really to commit to memory here. All right. So moving on down the arm, supercondular, humorous fractures. So supercondular fractures of the distal humorous.

You're going to see this most common in children two to seven years old. So most frequently in children, two to seven years old. So be looking for a child in the vignette. Supercondular fractures are actually the most common pediatric elbow fracture. As far as the mechanism of injury, foosh with the elbow extended. So Fush F-O-O-S-H with the elbow hyper-extended. So you're going to hear me saying that a lot. So extension fractures are actually going to account

for approximately 95% of all supercondular fractures. And this is typically going to be from a fush mechanism. So fush stands for fall on outstretched hand. And then in this case, the elbow is going to be hyper extended. Like we talked about before, this is really seen very commonly in children. And the reason is because children have this increased flexibility in their joints. They have this ligamentous laxity. And when they fall with their arm extended out, they're more susceptible to hyper extending the arm

when they fall. And then hyper extension is what generally leads to this type of fracture to a supercondular fracture. So remember, supercondular fuchs with hyper extension. Diagnosis, you're going to get an x-ray. And what you're looking for here is fat pads. So the only thing I really think you should be aware of, at least for imaging when it comes to supercondular fractures for the exam, are fat pads. So in a non-displaced or minimally displaced fracture of this region, sometimes you actually can't see the fracture. Sometimes it can't be visualized. And the only indication that a fracture is present is elbow fusion, like seen in an anterior sale or posterior fat pad signs. So let's talk about fat pads for a second. In the elbow, you have fat pads. Usually they're not visible on x-ray.

I'm going to talk about this a little bit more when we get to radial head fractures next. Your interior versus posterior, which can be normal, which can not. But generally, fat pads, particularly posterior fat pads, they're not visible unless you have an acute injury. And then this blood starts to collect. This hemarthrosis elevates the fat pads out of the cornoid and the electronon phosa, and that's what makes them visible on radiographs. And actually, in more than 90% of cases where imaging shows posterior fat pad displacement, a fracture is seen on initial or follow-up radiographs. So at the elbow, be looking for your fat pads.

And then also be aware there is something called an interior humeral line. If there's any displacement of this line, this can also indicate a displaced fracture. I don't think they're going to ask you about this, though. Just really focus on your fat pads. Now, complications. There's a lot of complications that can arise from a supercondular fracture, vascular insufficiency, nerve injury, compartment syndrome. So you want to make sure you're doing a complete neurovascular e-val in these patients. You need to check the sensory and the motor function of the medial, the median radial owner nerves. You want to assess the radial and brachial pulses.

What you really need to be looking out for an exam question when it comes to complications of a supercondular fracture is something called Volkman's Schemic Contracture. So this isn't common, but it's definitely tested on. So when you have this type of fracture and you have a vascular injury and swelling, this can potentially lead to compartment syndrome. And if that compartment syndrome isn't treated in a timely manner, the associated ischemia and infarction can lead to Volkman's ischemic contraction. So what this causes is you have this fixed flexion of the elbow,

the wrist extension of the MCP joints. To put it really simply, it's this claw-like deformity of the hands, fingers, and the wrist. So for the exam, if you see Volkman's contracture right away, be thinking of a supercondular fracture because while this can be seen with other types of injuries of the arm, it's most commonly seen with supercondular fracture. So associate those two in your head, Volkman's supercondler, supercondemns, or just remember what I did and remember my Volkswagen's in supercondition. So Volkswagen helps remember Volksman contracture. Supercondition helps remember supercondular fracture. So my Volkswagen's in supercondition, Volkswagen's and Superman's contracture.

contracture, supercondition helps you remember supercondular fracture. All right. So treatment is going to be splint versus surgical. Most displaced or minimally displaced fractures, you're going to apply a posterior splint and sling. Displaced fractures generally would be repaired surgically, closed versus open reduction with percutaneous pin placement. Nothing really to memorize here.

So for supercondular fractures, remember, this is very likely going to be a young child in the vignette. It's going to be a fush injury with hyper extension. and remember fall on outstretched hand. Look for your fat pads on x-ray. And then finally, remember your Volksman's contracture for potential complications. Remember, by Volkswagen's in supercondition. Okay, so next radial head fractures, there's really just a few things to know here.

The mechanism of injury is going to be another fush. So another fuchsier, like in supercondular humeral fractures and many other fractures of the arm, really. So fall onto an outstretched hand is the most common mechanism for radial head or neck fractures. Because this type of injury, there's this sudden impaction. on the radius and onto the capitulum. So as far as diagnosis, you're going to get your x-ray. You're looking for fat pads here again. Now, the fat pads and radial head fractures are even more important than supercondular fractures

that we just discussed before because non-displaced radial head fractures can very, very often be missed. And an elevated anterior and posterior fat pads may be the only sign of an occult radial head fracture. So you're looking for those fat pads in the vignette and in real life. I wanted to give you a little bit of extra knowledge while we're on the topic of fat pads. So anterior fat pads can actually be a normal variant, particularly in children, while a posterior fat pad should really never be visible. It'll almost always indicate trauma.

So again, remember, anterior fat pads can sometimes be a normal finding, while posterior will almost always indicate a fusion caused by trauma. And I used to remember anterior fat pads, interior with an A can be A-OK. and posterior fat pads with a P are always problematic. So anterior, a okay, posterior, problematic. It helps you remember which one can be normal, which one's always bad. Treatment is going to be split versus surgical. Nothing really to know here.

Depending on the severity of the fracture or mobilization with a sling or posterior split may be sufficient for surgical repair for your displaced or more severe fractures. Again, little enough for radial head fractures. Just remember your fush injury. You know your fat pads signed for those occult fractures. Occult fractures, if I didn't mention this before, it just means a hidden fracture that's not visible on imaging. Let's move on to ulnar shaft or nightstick fractures.

Really very little to know for this one. I only bring it up for some reason this does come up on exams. Main takeaway here is to know the type of injury that's related to the specific fracture. So this is going to be an isolated ulnar shaft fracture. The mechanism of injury is going to be a direct blow to the forearm. So these types of fractures almost always result from a direct blow to the forearm. So this happens when the patient was using the forearm to protect. their head from their torso, like from a blow, like with a nightstick or a pool stick or something

like that. So if you're familiar with the mechanism of injury when you see it in a vignette, you'll know you'll be looking for an ulnar fracture in the answers. Treatment is going to be non-operative treatment versus surgical repair. So casting, splining is the accepted approach for uncomplicated nightstick fractures. But if the fracture is common-uted over 50% displacement, these types of fractures are better suited for surgical repair. Okay, Montesia and Galiazi fractures. So with Montesia and Galeazi fractures, the only thing I feel you really need to remember that's normally tested on is what bonus fracture and dislocated in each. The rest of the stuff is pretty low yield that you need to know. So Montesia is going to be a proximal ulnar fracture accompanied by a radial head dislocation. So again, Montesia, proximal ulnar fracture accompanied by a radial head dislocation. Galiazzi is going to be a radial head dislocation. Galiazzi is going to be a radial head dislocation. midshaft fracture associated with a dislocation of the distal radial ulnar joint. So both of these are not just fractures, but they're also dislocations, and you need both to

meet the criteria for either a Montesia or a Galliazzi fracture. You need to have both the fracture and the dislocation. Diagnosis is going to be done with an x-ray. Treatment is going to be surgical repair generally in both a Montesia and a Galliazzi fracture. Treatment's almost always going to be surgical. Montesia fractures in particular are almost in particular almost always unstable and always require surgical treatment. Most of the time this is going to be with an ORIF open reduction internal fixation. So again, the highest yield thing is remembering which fracture and dislocation is of what bone in each condition. So the way that you remember that is by remembering gruesome murder. So gruesome murder helps to remember which bone is fracture and then secondly,

which is dislocated. So remember gruesome murder. So for Montesia and Galeazi fracture. So gruesome, the first three letters in gruesome are GRU. So the G stands for Galiazi, the R stands for radius fracture, and then the U stands for ulnar dislocation. So that's in gruesome, Galiazi, R radius fracture, and then the U stands for owner dislocation. I know technically I said this is a dislocation or instability of the radial owner joint, not specifically in owner dislocation, but in most cases what we actually see is this dorsally displace owner head, which will be very evident on x-ray. So you'll see the ulnar popped out of place. Remember, gruesome GRU, Galiazi, radius fracture, ulnar dislocation. And then murder, the second

part of the sentence. The first three letters are M-U-R, and that stands for M stands for Montesia. U stands for ulnar fracture. And then the R stands for radial head dislocation. So again, remember gruesome murder, first three letters of gruesome, Gali-Azi, radius fracture, ulnar dislocation, first three letters of murder, help you remember Montesia, ulnar fracture, and radial head dislocation. Okay, radial head subluxation. This is also known as a nurse-made elbow. It's important to know this because not only may it come up on an exam, but if you wind

up working anywhere with pediatric patients, you're going to see this very frequently. So what happens here, you have the movement of the head of the radius that slips under the annular ligament. So we talked about this before, but the ligaments and children are much more lax and weak. So in a child, when you have this sudden pulling on the arm, pulling on the distal radius, the annular ligament, which is a band of fibers that encircles the head of the radius, it slips right over the head of the radius, and then this slides into the radial humoral joint where it becomes trapped, and these children start to have pain.

It's most common in one to four years of age. So common between the ages of one to four years, 80% of cases are actually going to fall within the one to three year range. So if it's not a young child in the vignette, it's not a nurse-made elbow. This is 100% going to be a young child. The reason we see this more frequently in young children, not adults, is because the attachment of the anular ligament is much weaker in children than adults. As the child grows, the attachment between the anular ligament and the radius becomes thicker

and stronger, and it prevents the subluxication. Usually by the age of five years, the ligament is going to be strong enough and thick enough that it's highly unlikely to tear to become displaced. So generally, you're looking for a child one to four years. I'm not saying it's impossible to see this like in a seven or eight-year-old, but probably not very common at all. Look for a very young child in the vignette. Mechanism of injury, this is going to be a pulling injury.

So the classic mechanism for a radial head subluxation is going to be consisting of a pull injury. So for instance, a parent grabs the arm of the child to prevent them from falling. Maybe the child is being swung by the forearms or during play with their siblings or parents. You're looking for some type of pull or tug on the arm in the vignette. The reason why this was actually called a nursemaid level was because back in the day, when nursemaids, as they were called back in the day, took care of children, they were often blamed for causing this injury by tugging on the child's arm. So look for that pulling or tugging of the arm. Diagnosis is going to be clinical. So majority of the time, this is a clinical diagnosis. They had a pulling or tugging type injury. They fit the age range on physical exam. They don't have any bony tenderness, no deformity, no swelling. Usually that's all you need to make the diagnosis. Imaging is usually not necessary. Now treatment, there's

very few things in medicine where we can fix someone's problems in a matter of seconds and make them feel completely back to normal. But this is one of those few circumstances. So with treatment, it's going to be a closed reduction. And there's a couple ways to do this. The technique preferred by up to date, which has a higher rate of success, is reduction with hyperpronation rather than the other alternative, which is this suponation flexion. So the way you do the hyperpronation method is going to be you hold the child's arm at the elbow. You put it. You put a superpronation method. You place pressure with the finger on the radial head. And then the other hand holds the distal forearm and you hyperpronate the form. So you turn the arm all the way over and in. And a lot of times

you're going to feel this click or this pop over the radial head when it reduces. And then these kids within minutes are going to be back to normal and playing and smiling in most cases, at least from my experience. So for radial head subluxation, main takeaway here, looking for a child under five, looking for a pulling injury. It's a clinical diagnosis and treatment is going to be with a closed reduction. Very straightforward. All right. Meteoral head. versus lateral epicondylitis. These are really simple. There's very little to know, but the problem is you can easily get them mixed up and miss out on an easy exam question. So let's go over what you need to know, the little differences between the two and a mnemonic to remember them. So lateral

epicondylitis, which is also known as tennis elbow. It's a frequent complaint of tennis players, actually up to 50% of tennis players. It's mostly due to poor technique. So it's an overuse injury of the origin of the common extensor tendon, which leads to tendinosis and inflammation of the extensor carpi radialis brevis, precipitated by repetitive wrist extension. And the reason why you have pain in the lateral epicondial is because the lateral epicondal of the elbow is the bony origin for the wrist extensers. So who are you looking out for? This is going to be, of course, tennis players, like I said before, tennis is the most common sport to cause lateral epichondylitis. It can be seen in other sports, squash, badminton, as well as certain occupations like carpenters, bricklayers, seamstresses, but for the sake of the exam, be looking for your tennis player.

And on exam, you're going to be looking for localized tenderness over the lateral epicondial and pain with resisted wrist extension. So lateral epichondylitis associated with extension and extensor. So pain with wrist extension on physical exam, overuse of the extensor tendon, the extraceor. extensor carpi radialis precipitated from repetitive wrist extension remember I keep saying extension extensor lateral epichondylitis remember extension extension that's how they're going to get you on an exam question if you don't remember this and you get it mixed up with medial epicondylitis which is the opposite involving flexion rather than extension treatment it's going to be conservative enseds activity modification steroid injections counterforce braces not anything really important to know here medial epicondylitis so this

is also known as golfers elbow. It is a overuse injury involving the proximal tenders of the pronator terrace and flexor carpi radialis, probably mispronouncing all of these. I would imagine I am. It's primarily due to repetitive forceful forearm pronation and wrist flexion. So this is the opposite and lateral we are talking all about extension, extensor tendons, now in medial it's all about the flexion, flexor carpid radialis caused by repetitive wrist flexion. And just like we talk about before in lateral epichondylitis. The reason why you have pain in the medial epicondial is because the medial epicondial is the common origin of the forearm flexor and the proenator muscles. So in the vignette, you're probably going to get a golfer. Medial

epichondylitis, as we know, is called golfer's elbow. But interestingly enough, around 90% of cases are actually non-sports related, in particular occupational settings with repeated, forceful gripping during heavy labor like plumbers, carpenters, construction workers. But for the exam, I'd probably remember and focus on your golfers. On a physical exam, they're going to have localized tenderness over the medial epicondial and pain with resisted wrist flexion. So flexion, flexion, flexion, treatment is going to be the same as lateral, conservative, Ns, activity modifications, steroid injections, counterforce braces.

Nothing to memorize there. All right. So the main thing to remember for both, lateral epichondylitis, remember, tennis players pain with wrist extension against resistance problem with the extensor tendons caused by repetitive wrist extension lateral should equal extension in your mind now medial epichondylitis golfers pain with wrist flexion against resistance problem with the flexor muscles caused by repetitive wrist flexion medial should equal flexion in your mind if you can remember one by method of exclusion you can remember the other and here's how you're going to do that so with medial

epicondylitis, aka golfer's elbow, I want you to remember mini golf is fun. The M in mini helps you remember this is medial epicondial involved in golfer's elbow, golf obviously because this is also known as golfer's elbow. And then the F in Fun helps you remember this involves flexion, whether it's pain with wrist flexion against resistance on exam or the fact that it involves the flexor carpi radialis or that's caused from repetitive flexion. Mini golf is fun. Mini stands for Medial epicondal, golf for golfer's elbow, and F in fun for a flexion, flexor. And then, you know, lateral epicondylitis is the opposite, problems with extension, not flexion. So remember, mini golf is fun on your exam when you get a question on one of these because you're

very, you very likely will. And honestly, I had so much trouble remembering which was which until I came up with this mnemonic, and now I never forget. So remember, mini golf is fun. Okay, next I wanted to talk about two conditions that are also really easy to get mixed up on an exam, and they can have similar presentations. and then I'll teach you some ways to help differentiate. So that's going to be cubital tunnel syndrome and carpal tunnel syndrome.

So let's start with cubital tunnel syndrome, which is ulnar neuropathy. It's a compressive neuropathy of the ulnar nerve caused by compression in the medial elbow. Clinical manifestations, this is the highest yield thing to know right here. So paristhesia of the fifth finger and half of the fourth. So numbness tingling in the ulnar nerve distribution, that's going to be your most common initial complaints. So parisages of the small finger and only half of the ring finger. It's also possible to have radiating pain down from the elbow. Usually you're looking for parisages in the little finger and half of the ring finger. That's the key to remember here. So you're going to get a question. The

patient's going to have some tingling in their hand. The answer choice is they're going to have both cubital tunnel syndrome and carpal tunnel. You need to remember which has which nerve distribution. And this is the way that you remember it. So cubital tunnel starts at the little finger, the pinky and half of the ring finger, carpal tunnel starts at the big finger, the opposite end, the thumb or the first digit, all the way through the other half of the ring finger. So how do you remember that for the exam? Well, cubital starts with the letters, C-U-B, C-U-B, and as we know, cubs are little bears, bear cubs, and that helped to remember that cubital, C-U-B is the one that starts at the little finger, the pinky. And by method of exclusion, you can remember carpal tunnel started at the other end,

the big finger, the thumb. So as soon as you see cubital tunnel syndrome, thinking. of a cub cub a little bear remember this is the one that starts at the little finger carpal tunnel starts at the other hand at the big finger the thumb that's all i remember for the exam and i got the question right because i remember cubs are little animals cubital tunnel syndrome starts at the little finger so on physical exam there's a few different provocation tests for cubital tunnel but the one physical test i'd remember for this is the tinell sign as this is the one you'll hear most often or the tennel test so this is just percussion or tapping over the ulnar nerve and the old grove of the elbow at the cubital tunnel. So when you do this, if they have parisetia and the fourth

and the fifth finger, that's a positive tennel sign. There's also a tennel sign or test in carpal tunnel as well, so don't get them mixed up. We'll go over that next. Treatment for cubital tunnel is going to be conservative for surgical. Initially, you start with activity modification. If this is from some sort of repetitive trauma or occupational cause, you can use splints and seds. Surgery is really only going to be for severe or progressive symptoms. Now, let's talk about carpal tunnel syndrome. So this is compression of the median nerve as it travels through the carpal tunnel. So cubital tunnel syndrome was ulnar nerve compression.

Carpal tunnel is median nerve compression. Different nerves affected, different nerve distribution and different area affected. So again, this is the really important thing you need to remember to differentiate the two. So in carpal tunnel syndrome, you're going to have pain and parisdia of the first three digits and half of the fourth. So a lot of times the pain is going to be present at night. it's going to wake them from sleep. The Hallmark presentation, Painter Parasthesia, and the distribution that includes the median nerve territory.

So thumb, the first digit, all the way through the fourth digit, the radial or lateral half. So first, second, and third, and half of the fourth fingers, different than cubital tunnel, which we know started at the opposite end of the hand, at the little finger, fifth digit, and half of the other half of the fourth digit on the owner's side. So carpal tunnel, fingers one, two, three, and half of four. Cubital tunnel, finger five, and half of four. Other things to look out for, although not as important, they may have weakness or clumsiness when using their hands. They may have difficulty holding objects, turning keys or doorknobs, buttoning clothing.

They may have atrophy of the thinner eminence in advanced cases. So those are just some other things to be aware of. Now, risk factors, there's a lot of risk factors for carpal tunnel. Obviously, repetitive hand and wrist use, particularly with some occupations, arthritis, obesity, female gender. But the ones that I would focus on for the exam are preemptive. pregnancy, third trimester is usually where the symptoms will start to manifest. It can be diagnosed earlier on than this though. Diabetes, malitis, both type 1 and type 2 diabetes, can be associated with carpal tunnel syndrome.

And then hypothyroidism. So hypothyroidism contributes to the development of carpal tunnel by increasing peripheral tissue edema. So those are usually the ones you're going to get tested on. Let's talk about one other high yield area for carpal tunnel that you'll definitely need to know for your Oskies. That's your physical exam test. So there's a few provocative maneuvers you'll hear about for carpal tunnel. The two that you need to know, the ones that frequently come up, are the Tenel test and the Phelan Test. So Tenel test, just like in Cubital Tunnel, where we tapped on the cubital tunnel.

Now we're tapping or percussing over the carpal tunnel. It's easy to get these physical exam tests mixed up. So I used to remember the T and Tenel stood for tapping because it helps you remember the test is performed. So you're tapping, tapping, tapping on the median nerve over the carpal tunnel. positive test is defined as pain or paristhia of the median innervated fingers. So remember first finger through half of the fourth. And then we have the phalan test. So the phelan test is performed by having the patients bring the dorsal surfaces,

so the back of the hands against each other, pushing them up, against each other at the top of the hands. Push them together and this provides hyperflection of the wrists while the elbows are going to remain flexed. You do this for one minute straight. And a positive test is going to be pain or pariscia again in the median innervated fingers. The way that I used to remember this is if you actually look at a picture of the Phelan test, when you flop your hands down like this, it looks like your hands have just kind of like flopped over. They've fallen over. So when I see Phelan test, I just remember that your hands have Phelan over because the hands are flopped over.

They look like they've fallen or failing over. So just remember Phelan, your hands have Phelan or fallen over. Tinell, remember, Tinell for Tinell on tapping, tapping on the median nerve, Phelan, hands have Phelan over, pressed up again. each other for a minute. Those are the two provocation tests I'd know for carpal tunnel. Also be aware there are nerve conduction studies, electromagnography. Those are some other diagnostic tests that can help you with the diagnosis, but focus on those physical exam tests. I talk about the tennel and the phalan treatment, conservative or surgical. So splinting glucocorticoids,

whether it's peel or via injections, are going to be useful for symptom relief and up to two-thirds of patients with mild or moderate carpal tunnel. Severe refractory cases, of course, surgical decompression may be needed. Let's move on to our scale. scaphoid or our navicular fracture. This is your most common carpal fracture. So scaphoid fractures are the most common carpal bone fracture. They're seen in around 60 to 70% of all carpal fractures. So this is an important one to know that's often tested on mechanism. Another fuchsher. So fuchs fall in an outstretched hand will likely be the cause of a scaphoid fracture or really any other injury that involves an axial load placed on the wrist on physical exam.

They're obviously going to have some pain in the wrist, but where is the pain going to be? It can be a few different places. It can be distal to the listerous tubercle, the voler prominence, but the only one that you have to know, the one that will 99% be how it's described in the vignette, will be pain or tenderness at the anatomic snuffbox. Know this for the exam. As soon as you hear anatomic snuffbox tenderness, be thinking scaphoid fracture always. So any tenderness in the snuff box should be treated as a scaphoid fracture until proven otherwise.

The snuffbox is located just proximal to the base of. the thumb. Now diagnosis, you're going to order a wrist x-ray, obviously, you want to include a scaphoid view. The thing about scaphoid fractures, though, is that they can be missed on x-rays pretty often. X-rays taken soon after the injury can be missed up to 54% of cases, so half the time. So if the history and physical exam findings are suspicious for a scaphoid fracture, but the x-rays are negative, you're often going to have to send these patients for a CT or MRI because if you miss a scaphoid fracture, the scaphoid unfortunately has a crappy fracture. The x-rays blood supply and can be at risk for non-union osteoencrosis.

So if it fits the picture of a scaphoid fracture, but the x-rays are negative, you still treat it like a fracture until you can definitively say otherwise. Treatment, thumb spica, treatment for majority of patients with a non-displaced fracture, or those patients who have negative x-rays but have snuffbox tenderness, you give these patients a thumb spica until you can rule out a fracture. With the scaphoid, again, treat it like a fracture until you know it ain't. surgery, if it's a displaced fracture or there's neurovascular compromise, surgical repair will be appropriate.

But in most cases, it's going to be your thumb spike of splint will be the answer choice. All right, let's talk about distal radius fractures. Our collies versus our Smith fractures. It's really just a few things to know here, mainly just being able to differentiate between a collies and a smith fracture. Mechanism, again, foosh, most common mechanism of the distal radius fracture is going to be falling on an outstretched hand. More of the, more often the, the, more often the,

wrist is going to be extended in a collies fracture injury and often you'll see it's flexed in a smith fracture so just a little side note there on physical exam collies fractures have what's known as a dinner fork deformity and this is due to the dorsal displacement of the distal fragment collies type fractures are often said to have this dinner fork appearance if you want to see some pictures i have it in the youtube video and then smith fractures are sometimes described as a garden spade deformity don't go too crazy memorizing these names, Dinner for a Garden Spade, because they're likely not going to use these buzzwords.

You just need to remember that one has dorsal displacement, the other has eventual displacement. I'm going to give you a mnemonic for that in a second. But remember, I guess, Smith fracture is sometimes known as a garden spade deformity. And that's if you see like a spade or a shovel, it has this little bump on it, and that's because of the eventual displacement. It looks like that.

Anyways, diagnosis, this is what you really need to know. So when you take an x-ray on a collie's fracture, you're going to see dorsal displacement of the distal radius fracture. Dorsal displacement of the distal radius fracture and a collies fracture and a Smith fracture, you're going to see voler or palmar displacement of the distal radius fracture. So remember, Collie's dorsal displacement, Smith, Volar or Palmer displacement of the distal radius fracture. That's the highest yield thing to know because this is what differentiates the two, and it may be the only difference in the vignette.

So remember, collie's fracture, dorsal angulation of the radius, Smith fracture of vular angulation of the radius. The way that you remember that a collie's fracture is dorsal displacement is because a collie is actually a breed of a dog nice and conveniently. It's the same dog that lassie was on that show a number of years ago. So a collie dog, when you think of a collie fracture, think of a collie dog. And the first two letters in dog are the first two letters in dorsal, DO. So this helps you remember collie's fractures are d o dorsally angusolidated radial fracture.

And by method of exclusion, Smith is the opposite, volar angulated radial fractures. So when you see collie fracture, think of a collie dog D-O-dorsal dog. Treatment split for split reduction for surgery. So some fractures can be treated with closed reduction. Sugar tongue splint, other fractures are going to require surgical repair depending on the severity. Remember, your collie dog dorsal angulation for your collie fracture. Just knowing that one thing may get you the question. Very likely it will.

If you ever forget which side is the dorsal side of the hand or the wrist, remember the dorsal fin of a dolphin is on its back. Therefore, a fracture with dorsal angulation will be angulated toward the back or the top of the wrist area. All right, lunate fractures. So lunate fractures are pretty uncommon. They only account for about 4% of all carpal wound injuries, but they do have some pretty serious complications if they're not treated. So mechanism of injury is going to be another fall on an extended wrist or any other type of wrist hyper extension injuries. these are going to be your most common mechanisms of injuries for a lunate fracture. Diagnosis, so x-ray.

The main thing to know about x-rays of the lunate is that they're missed quite often with plain radiographs. So if there's any clinical suspicion, it's important to obtain advanced imaging like CT or MRI. CT is going to be preferred. One other thing that I wanted to mention because it may come up. If you have a dislocation of the lunate bone, the lunate gets displaced and angled in this volar direction. And in comparison to the surrounding structure is the disloat. distal radius, metacarpals, which are all in normal alignment. It looks like a teacup spilling over on lateral x-rays, at least that's what they say, and it's called a spill teacup sign.

So just in case you hear that being mentioned at any point, you'll know this is what can be seen in a lunate dislocation. So you need to know a complication, avascular necrosis, and Kynbach disease. So progressive collapse of the lunate mechanism of injury is really unclear. This is Kynbach's disease, so it's a progressive collapse of the lunate mechanism of injury. mechanism is really unclear. It involves to appear some disruption of the blood supply. It's likely related to undiagnosed fractures of the lunate. Some other complications with lunate fractures are complex regional pain syndrome osteoarthritis. Nothing specific I would know for the treatment for lunate fractures except in the case of a dislocation in which immediate reduction is really

important to prevent a number of complications. So again, that's your lunate fractures and a little bit about dislocations, not a lot to know there. Let's talk about decoravine tendonopathy next. So this is a thickening of the abductor polisus longest, the APL, and extensor polysis brevis, the EPV tendons, and the tunnel or the sheath in the first extensor compartment. So the abductor polisisus longest, APL, the extensor polisus brevis, EPB tendons, they pass through this tunnel called the fibro-osius tunnel from the forearm into the hand.

and any thickening of these tendons passing through here or thickening of the tunnel itself can restrain the gliding motion through the sheath which can lead to the clinical manifestations will go over. So think of a rope going through a little hole and the rope's getting bigger or the hole's getting smaller. Eventually it's going to get stuck. I don't recommend memorizing abductor polysis longest and extensor polis brevis. Those are hard enough to say. It's just too much brainpower to memorize those complicated names. What I would recommend memorizing, though, is apples with extra peanut butter are delicious, because if you can remember that apples spelled APL, APL as an APL tendon with extra peanut butter,

EPB as an EPB tendon, are delicious as in decoravean tendinopathy. If you can remember that, that helps you remember your APL tendon and your EPB tendon are going to be involved in this decorvene's tendonopathy. and this should be enough for you to be able to pick them out on the multiple choice question by remembering the letters involved in the full name. So if you can remember abductor policies longest and extensor policies brevis, in addition to the 20,000 other things you need to offer for PA school, more power to you.

But I just remembered apples with extra peanut butter are delicious. That was enough for me to help pick out the right answer on my clinical medicine exam. So apples again, APL, extra peanut butter, EPB, are delicious decoravine tendinopathy. You're done. All right. So what about the patient demographic you're looking for? So you are going to be looking for women between the ages of 30 to 50 years of age, and then it's also prevalent in a subset of women in the postpartum period. Symptoms usually are going to present about four to six weeks after delivery.

There's a lot of theories why this happens in the postpartum period. Repetative motion of the hands required to lift and hold newborns, hormonal causes, fluid retention, whatever the case. In the vignette, you're looking for both women in the 30 to 50 year age range and also postpartum women. clinical manifestations, they're going to have pain at the radial side of the wrist. It's going to be worse with thumb and wrist movement. So the tendons we went over before the EPB and the APL are responsible for movement of the thumb. So you can imagine a lot of the complaints are going to be related to thumb movements since the EPB and the APL are responsible for movement of the thumb. Diagnosis. So de-quivain tendonopathy is based upon the history of an at traumatic radial wrist pain and positive physical exam finding. So imaging like x-ray is not really necessary except to rule out other differentials, which may have a similar presentation like osteoarthritis. The main thing to know for diagnosis is a physical exam maneuver called the Finkelstein test. So the Finkelstein provocation test involves the patient wrapping their fingers around their thumb, clasping it in their palm, and then you apply ulnar deviation to the wrist.

If they have pain over the radial styloid area, so the base of the thumb, this is considered a positive test. Again, that's the Finkelstein test. Treatment, thumb spikas splint is going to be the big one, nsides, glucocorticoid injections. So decoravean tendinopathy is generally non-progressive. It's typically self-limited. So most of your conservative measures are going to be your mainstay. Again, thumb spikas splint is commonly used, N-sad steroid injection surgery really is only to be for refractory cases. So I'll talk about mallet finger necks.

So this is a finger deformity caused by traumatic disruption of the terminal slip. the extensor tendon at the distal interphalangeal joint, so the DIP joint. So you have some sort of trauma to the finger usually caused by a direct blow to the tip of the finger. So maybe a ball striking the fingertip or the fingertip strikes a hard surface. The trauma causes a tear in the extensor tendon at the DIP joint. And this is the tendon that allows you to extend your fingers, so to hold them out straight. And with this being torn, you can no longer do that. So the finger remains in this constant state of flexion.

physical exam they're going to have an inability to extend the DIP joint. This is going to result in that flex DIP. So it's really simple. Patients are going to have this constant flexion of the DIP joint. They're not going to be able to extend the finger at that joint. This specific degree of the DIP angulation is often going to reflect the severity of the tendon disruption. Now diagnosis, X-ray. So in some cases with the mallet finger, you're going to visualize a bony evulsion of the distal phalanx at the site where the tendon attaches. It just got ripped off during the injury. It's also possible just to have just a ligamentous injury with normal bony anatomy. So you can see either one.

Now, treatment, really important, extension splinting of the DIP joint for six to eight weeks with 24 hours of maintaining this extension. So the DIP joint must be maintained at full extension throughout the entire period, including during sleep. If the joint extension is lost at any point during this initial treatment period, the treatment clock is reset and an additional six weeks of splinting has to be performed. So if you think about it, you're keeping those torn tendon edges aligned. So as soon as you bend that finger, just rips, it tears all over again. So the only way for it to completely heal is to have that finger in full extension with the torn ligament aligned for six to eight weeks. The majority of malif fingers are amendable to treatment with just splinting. Surgery is really only going to be reserved for large displaced fractures or other complex injuries that may warrant resurgical referral.

But really focus on splinting as that's going to be your most common, your mainstay treatment. So mallet finger again, extensor tendon injury, DIP joint now flex all of the time. They can't extend it. Straighten it out with a splint done. That's your mallet finger. Now let's talk about ulnar collateral ligament injury, aka a gamekeeper or skier's thumb. It's an injury caused by damage to the ulnar collateral ligament of the thumb. Mechanism of injury is going to be a forced abduction, abduction, and hyper extension of the thumb.

This is going to be at the metocarpal phalangeal joint. that's going to be your most common cause. So the thumb is stretched and forced into extreme abduction, whether this is from a fall, athletic injury, skiing accidents, where the thumb strikes a fixed ski pole. And that's where the name skier's thumb came from. Or the name Gamekeeper's thumb, so not so relevant anymore. But basically, this was this chronic degeneration of the ulnar collateral ligament

from twisting the necks of too many birds and rabbits. So I'm not making that up. That's what Gamekeeper's thumb came from. So yeah, probably won't be the reason why your patient comes in with this, but 70 plus years ago when the name was created, it was. Today, most often this is going to be a skiing-related injury or another athletic-related injury. On physical exam, you can pretty much confirm a UCL injury with your physical exam findings combined with your appropriate clinical manifestations. So valgus stress testing is going to reveal a loss of integrity of the UCL. So the injured thumb will have increased laxity of the MCP joint.

So the thumb, you're going to be able to pull much further away compared with the uninjured thumb when valgus stress is applied. So if the test is positive and the patient has the classic clinical manifestations, pain exacerbated by thumb extension or abduction and swelling along the ulnar aspect of the thumb at the MCP joint, this is going to help to confirm the diagnosis. But you also want to get an x-ray of the thumb to rule out any possible bony avulsion fractures. And definitive diagnosis can be made with an MRI or ultrasound, but generally it's not necessary. treatment thumb spica splint so mobilization with the thumb spica will be sufficient in most patients some patients with a complete tear or patients that don't respond to conservative therapy may require surgical intervention boxers fracture this one's pretty much straightforward it's a fracture of the fifth metacarpal neck generally the fifth metacarpal neck fractures when we're talking about boxer fractures occasionally sometimes

you'll hear being referred to fractures of the fourth metacarpal as well but not as common mechanism of injury, direct trauma to a clenched fist. So obviously the most common situation where you're going to have direct trauma to a closed finch, or what did I just say, a clenched fist would be punching something. So that's going to be the most common cause. So whether they're punching a wall, a solid object, a face, that's why it's called a boxer's fracture. In reality, though, experienced boxers actually rarely sustain this type of fracture. It's more the wild roundhouse punching motion that's common in street fights that caused this, or someone who punched a brick wall is going to come in with this type of fracture rather than Floyd Mayweather who's trained

to punch the right way. Diagnosis you're going to be made with x-ray, so plain radiographs of the hand. This is going to establish the diagnosis of a metacarpal neck fracture, and this will also help to determine the degree of the fracture angulation. So treatment is going to be with immobilization with an ulnar gutter splint. So owner gutter splint is going to be, it's going to be used to immobilized fractures of both the fourth and the fifth metacarpal necks. If the patient does have an open fracture, a severely commonuted fracture, or if they have significant angulation normally over 30 to 40 degrees, this is going to require a surgical consult. Otherwise, you mobilize it with a splint. All right, let's finish up with something a little bit different. And because I feel like I can no longer

talk, keep getting stumbling on my words, let's finish up with complex regional pain syndrome. So this is an array of painful conditions that are characterized by a continuous, regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. That's the official definition. So basically these patients have this prolonged pain. It's completely disproportionate to the initiating event. Most frequently this is going to follow a bone or soft tissue injury.

So most cases there's going to be some sort of injury, sprain, fracture, etc. In some cases there may be no precipitating factor. It's not common. And then weeks later, they're going to start to develop. this range of clinical manifestations. Autonomic dysfunction, pain out of proportion to the initial injury, hair and nail changes. The patho is really unknown. There's some proposed mechanisms, but definitely nothing to know for the exam. Now, in clinical manifestations, this is the most important thing about complex regional pain syndrome. It's the presentation. The diagnostic criteria

is low yield. The treatment is low yield. It's all about being able to recognize the clinical manifestations. That's what you need to know for the exam. So the main clinical manifestations of complex regional pain syndrome are pain sensory changes motor impairments autonomic symptoms and trophic changes in the affected limb this is usually going to occur four to six weeks after the inciting event the reason i'm covering this under the upper extremity section for the pants is because this most commonly occurs in the upper extremity around 60% of the time so the way that i used to remember the common clinical manifestations that you're going to see in a vignette for complex regional pain syndrome is by remembering instead of complex regional pain syndrome

I want you to remember complex regional paint syndrome. So P-A-I-N-T, complex regional paint syndrome. And what does paint stand for? So paint stands for, the P stands for perspiration, and this is due to the autonomic dysfunction. So 40% of patients are going to experience increased sweating on the side where they're experiencing this. The A in paint stands for after injury. So after injury for the A, because remember this is most commonly going to take place after some sort of bone or soft tissue injury. So look for some sort of injury mentioned in the vignette weeks prior.

The eye and pain stands for inappropriate pain because remember the pain experience is inappropriate. It's out of proportion to the initial injury. Pain is typically the most prominent and debilitating symptom of complex regional pain syndrome. So remember, I stands for inappropriate pain because it's not appropriate to have 10 out of 10 pain in your wrist from a sprain you had two months ago. So remember inappropriate pain for eye. The N stands for nail changes. So remember I talked about before your trophic change. So these patients may have increased or decreased nail growth.

Also look for hair growth changes as well. But remember, N stands for nail changes from your trophic changes. And then the last letter T in paint stands for temperature changes. So this relates back to those autonomic changes. Again, these patients can have. And some patients are going to see a difference in skin temperature on the affected side versus the unaffected side of over 1 degree Celsius. So remember, if you have a vignette, you think the patient they're talking about, may

have complex regional pain syndrome, remember to look for paint. Perspiration, after injury, inappropriate pain, nail changes, temperature changes, and that should be enough to get you there and get the right answer. Now diagnosis, clinical features based on your H&P. So the diagnosis is really just based upon the clinical features determined by your history and physical. So nothing really to know for the exam question. You're basically looking to see, are they having pain, sensory changes, motor symptoms, autonomic dysfunction, are these symptoms weeks out from an initial injury that would no longer be appropriate to persist at this point in time. There are some imaging tests that can be used, three phase bone, scintigraphy,

radiographs, but there's nothing high yield. There's no gold standard test. Definitely nothing I would memorize for the exam. So just know this is generally a clinical diagnosis. Are they experiencing paint? If so, complex regional pain syndrome. Treatment is multifaceted. Physical therapy, inseds, tricyclic antidepressants, sympathetic nerve blocks.

physical and occupational therapy are more or less considered first-line treatment for complex regional pain syndrome. But again, it's a multifaceted, multidisciplinary approach. There's not one specific thing to know for treatment. The main takeaway for complex regional pain syndrome to identify in a vignette is to remember the symptoms that you're seeing in these patients. The treatment's really not high yield. Diagnostic criteria is really not that high yield.

It's being able to recognize it in a vignette. So remember, complex, regional paint syndrome, perspiration after injury, inappropriate pain, nail changes, temperature changes. That's the main takeaway here, and we are done with the upper extremity. Let's do five quick questions. Question one, 32-year-old female presents to the office complaining of pain at the radial side of her wrist that is most prominent upon movement of the thumb.

She is four weeks postpartum past medical history is otherwise unremarkable. On exam, tenderness is noted over the radial styloid, and pain is experienced with passive ulnar deviation of the wrist, with the thumb flexed. in the palm. What is the likely diagnosis in this patient? So that is going to be de-quare-vein tendonopathy. So de-quare-veined tendonopathy, we know, is most commonly seen in women between the 30-to-50-year age. Also common to see in postpartum women, four to six weeks after delivery. So she fits this criteria to the T. Then she states she has pain on the radial side of the wrist, and then a physical exam tenderness over the radial styloid. She has a positive Finkelstein test where the patient's

wrist. It's put into owner deviation. All the patient's fingers are folded over the thumb. This is a classic presentation for decarbe and tendonopathy. Question two, a 43-year-old female presents to the office complaining of numbness and tingling in her hands, mostly affecting the thumb index and middle finger and part of the ring finger. She states that as worse at night, sometimes waking her from sleep. Both a tinell and a phalan test are positive on physical exam. This patient is likely experiencing compression of which nerve. So that is going to be, the median nerve. So this patient is experiencing carpal tunnel syndrome, which is compression of the medial nerve. Median nerve. So we know this because the patient has peresthesia's in the median

nerve territory, which will be the first three fingers and radial half of the fourth. In addition, she states it's worse at night, which is very common for carpal tunnel. Finally, we have a positive tunnel and phalan test that seals the deal. We know this is carpal tunnel, which is median nerve compression. Question three, 27-year-old male presents to the ER after a bicycle accident he had earlier on in the day. He states his bike hit a pothole which sent him flying off his bike landing onto his outstretched hands. He's now complaining of pain along the radial side of the wrist and is tender just proximal to the base of the thumb at the anatomic snuff box. Fracture of which bone should be suspected in this patient until proven otherwise. So that is going to be the

scaphoid. This is a simple one, scaphoid or navicular fracture. You have a patient who had have fallen to an outstretched hand, which is often the mechanism of injury for a scaphoid fracture. He has pain on the radial side of the wrist. Snuffbox tenderness, you are done. That is a scaphoid fracture until proven otherwise. As soon as you hear snuffbox, always be thinking of a scaphoid fracture. Question four, 67-year-old male presents to the office today complaining of persistent elbow pain. He does not recall any trauma to the elbow, but the pain he is experiencing in his elbow

is affecting his golf game as he is an avid golfer. On exam pain is elicited by performing wrist flexion against resistance. Tenderness would likely be felt in which part of the elbow in this patient. So that would be at the medial epicondial. So we have a classic case of medial epicondylitis, aka golfer's elbow. You have a 67-year-old male, avid golfer with elbow pain, no preceding trauma. And then the key is that the pain is reproduced on exam with the wrist being flexed against resistance. So in this case, the patient wouldn't have pain in the medial epicondial.

of course remember the demonic mini golf is fun and mini helps you remember this is the media epa condo involved in golfer golfers elbow golf because this is known as golfer's elbow and then the f in fun helps you remember this is going to involve flexion whether it's pain against risk uh pain with wrist flexion against resistance on exam the fact that it involves the flexer carbary radiolus or that it's caused from repetitive flexion mini golf is fun helps you remember all the things that you need to know and then by method of exclusion you know lateral epicondylitis is the opposite problems with extent not flexion. Last question. Question five. 17 year old male presents to the ER after sustaining an injury to his right arm. After x-rays are complete, the attending physician assistant informs him

that the x-ray revealed a proximal ulnar fracture accompanied by a radial head dislocation. This type of injury is also known as a, and that is going to be a Montesia fracture. So remember, gruesome murder, Montesia and Galeezy fracture. Grusome, first three letters in gruesome stand for Galiazi. R stands for radius fracture, U stands for only dislocation, aka the radial owner joint, and then murder, which is the first three letters, M-U-R, Montesia, U stands for ulnar fracture, and R stands for radial head dislocation, which is the type of injury we see here in this patient. All right, that is the upper extremity for the MSK section for the pants. Thank you so much for listening to the podcast, and good luck in PA school, good luck on your pants or panery at EORs, and thank you again.