anatomia extremidad superior
drojitos
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About This Presentation
muy buena expo pero esta en ingles
Slide Content
AnatomyAnatomy
Lecture 7Lecture 7
Upper ExtremitiesUpper Extremities
Physician Assistant ProgramPhysician Assistant Program
Miami Dade CollegeMiami Dade College
Lecture 7Lecture 7
Upper ExtremitiesUpper Extremities
Physician Assistant ProgramPhysician Assistant Program
Miami Dade CollegeMiami Dade College
“ “I will persist until I succeed”.I will persist until I succeed”.
Og Mandino Og Mandino
Og Mandino Og Mandino
ShoulderShoulder
ShoulderShoulder
1. Glenohumeral Joint: 1. Glenohumeral Joint: A spheroidal (ball & socket) joint that is the principal A spheroidal (ball & socket) joint that is the principal
articulation of the shoulderarticulation of the shoulder
Inferior Glenohumeral ligamentInferior Glenohumeral ligament
A major anterior stabilizer of the glenohumeral joint, especially with A major anterior stabilizer of the glenohumeral joint, especially with
the arm abductedthe arm abducted
Middle Glenohumeral ligamentMiddle Glenohumeral ligament
Prevents anterior instability when the shoulder is externally rotated Prevents anterior instability when the shoulder is externally rotated
and abducted 45 degreesand abducted 45 degrees
Superior Glenohumeral ligamentSuperior Glenohumeral ligament
Works with the coracohumeral ligament to prevent inferior instability Works with the coracohumeral ligament to prevent inferior instability
in the adducted armin the adducted arm
LabrumLabrum
Is a fibrocartilagenous thickening surrounding the glenoid that Is a fibrocartilagenous thickening surrounding the glenoid that
deepens the glenoid cavity. deepens the glenoid cavity.
It prevents abnormal motion and serves to anchor the inferior It prevents abnormal motion and serves to anchor the inferior
glenohumeral ligament complexglenohumeral ligament complex
1. Glenohumeral Joint: 1. Glenohumeral Joint: A spheroidal (ball & socket) joint that is the principal A spheroidal (ball & socket) joint that is the principal
articulation of the shoulderarticulation of the shoulder
Inferior Glenohumeral ligamentInferior Glenohumeral ligament
A major anterior stabilizer of the glenohumeral joint, especially with A major anterior stabilizer of the glenohumeral joint, especially with
the arm abductedthe arm abducted
Middle Glenohumeral ligamentMiddle Glenohumeral ligament
Prevents anterior instability when the shoulder is externally rotated Prevents anterior instability when the shoulder is externally rotated
and abducted 45 degreesand abducted 45 degrees
Superior Glenohumeral ligamentSuperior Glenohumeral ligament
Works with the coracohumeral ligament to prevent inferior instability Works with the coracohumeral ligament to prevent inferior instability
in the adducted armin the adducted arm
LabrumLabrum
Is a fibrocartilagenous thickening surrounding the glenoid that Is a fibrocartilagenous thickening surrounding the glenoid that
deepens the glenoid cavity. deepens the glenoid cavity.
It prevents abnormal motion and serves to anchor the inferior It prevents abnormal motion and serves to anchor the inferior
glenohumeral ligament complexglenohumeral ligament complex
ShoulderShoulder
2. Sternoclavicular Joint: 2. Sternoclavicular Joint:
Gliding joint with discGliding joint with disc
anchors shoulder girdle to chest wall (sternum to anchors shoulder girdle to chest wall (sternum to
clavicle)clavicle)
3. Acromioclavicular joint:3. Acromioclavicular joint:
Gliding joint with incomplete disc. Gliding joint with incomplete disc.
Attaches acromion and clavicleAttaches acromion and clavicle
4. Scapulothoracic joint:4. Scapulothoracic joint:
Medial border of scapula articulates with posterior Medial border of scapula articulates with posterior
aspect of ribs 2-7aspect of ribs 2-7
The ratio of glenohumeral to scapulothoracic motion The ratio of glenohumeral to scapulothoracic motion
during shoulder abduction is 2:1during shoulder abduction is 2:1
2. Sternoclavicular Joint: 2. Sternoclavicular Joint:
Gliding joint with discGliding joint with disc
anchors shoulder girdle to chest wall (sternum to anchors shoulder girdle to chest wall (sternum to
clavicle)clavicle)
3. Acromioclavicular joint:3. Acromioclavicular joint:
Gliding joint with incomplete disc. Gliding joint with incomplete disc.
Attaches acromion and clavicleAttaches acromion and clavicle
4. Scapulothoracic joint:4. Scapulothoracic joint:
Medial border of scapula articulates with posterior Medial border of scapula articulates with posterior
aspect of ribs 2-7aspect of ribs 2-7
The ratio of glenohumeral to scapulothoracic motion The ratio of glenohumeral to scapulothoracic motion
during shoulder abduction is 2:1during shoulder abduction is 2:1
ShoulderShoulder
5. Supporting structures (from superficial to 5. Supporting structures (from superficial to
deep layers)deep layers)
A. deltoid, pectoralis majorA. deltoid, pectoralis major
B. clavicopectoral fascia, conjoined tendon, B. clavicopectoral fascia, conjoined tendon,
pectoralis minorpectoralis minor
C. subdeltoid bursa, rotator cuff musclesC. subdeltoid bursa, rotator cuff muscles
D. glenohumeral capsule, coracohumeral D. glenohumeral capsule, coracohumeral
ligamentligament
5. Supporting structures (from superficial to 5. Supporting structures (from superficial to
deep layers)deep layers)
A. deltoid, pectoralis majorA. deltoid, pectoralis major
B. clavicopectoral fascia, conjoined tendon, B. clavicopectoral fascia, conjoined tendon,
pectoralis minorpectoralis minor
C. subdeltoid bursa, rotator cuff musclesC. subdeltoid bursa, rotator cuff muscles
D. glenohumeral capsule, coracohumeral D. glenohumeral capsule, coracohumeral
ligamentligament
FindingFinding Significance Significance
Muscle wastingMuscle wasting Chronic rotator cuff tear, Chronic rotator cuff tear,
nerve injurynerve injury
““Popeye” musclePopeye” muscle Proximal rupture of Proximal rupture of
long head of bicepslong head of biceps
Scapular wingingScapular winging Serratus anterior (long thoracic Serratus anterior (long thoracic
nerve) injurynerve) injury
Superior prominence Superior prominence Acromioclavicular Acromioclavicular
(piano key sign)(piano key sign) separation/ clavical fracture separation/ clavical fracture
Anterior prominenceAnterior prominence Glenohumeral dislocation, Glenohumeral dislocation,
sternoclavicular injurysternoclavicular injury
Systemic hyperlaxitySystemic hyperlaxity Multidirectional Multidirectional
instabilityinstability
Muscle wastingMuscle wasting Chronic rotator cuff tear, Chronic rotator cuff tear,
nerve injurynerve injury
““Popeye” musclePopeye” muscle Proximal rupture of Proximal rupture of
long head of bicepslong head of biceps
Scapular wingingScapular winging Serratus anterior (long thoracic Serratus anterior (long thoracic
nerve) injurynerve) injury
Superior prominence Superior prominence Acromioclavicular Acromioclavicular
(piano key sign)(piano key sign) separation/ clavical fracture separation/ clavical fracture
Anterior prominenceAnterior prominence Glenohumeral dislocation, Glenohumeral dislocation,
sternoclavicular injurysternoclavicular injury
Systemic hyperlaxitySystemic hyperlaxity Multidirectional Multidirectional
instabilityinstability
ExamExam Technique Technique Significance Significance
Impingement sign passive forward flexion Impingement sign passive forward flexion pain = >90 degrees pain = >90 degrees
impingement syndrome impingement syndrome
Impingement Test same after subacromial relief of pain= Impingement Test same after subacromial relief of pain=
lidocaine lidocaine impingement syndrome impingement syndrome
Hawkins Test passive forward flex to pain= impingement synd Hawkins Test passive forward flex to pain= impingement synd
(Dump out can) 90 & internal rotation (Dump out can) 90 & internal rotation
Apprehension Test Abduction to 90 & Apprehension Test Abduction to 90 & + appreh test= ant. + appreh test= ant.
external rotationexternal rotation shoulder instability shoulder instability
Sulcus signSulcus sign downward traction sulcus below downward traction sulcus below
on arm on arm acromion=inferior laxity acromion=inferior laxity
Impingement sign passive forward flexion Impingement sign passive forward flexion pain = >90 degrees pain = >90 degrees
impingement syndrome impingement syndrome
Impingement Test same after subacromial relief of pain= Impingement Test same after subacromial relief of pain=
lidocaine lidocaine impingement syndrome impingement syndrome
Hawkins Test passive forward flex to pain= impingement synd Hawkins Test passive forward flex to pain= impingement synd
(Dump out can) 90 & internal rotation (Dump out can) 90 & internal rotation
Apprehension Test Abduction to 90 & Apprehension Test Abduction to 90 & + appreh test= ant. + appreh test= ant.
external rotationexternal rotation shoulder instability shoulder instability
Sulcus signSulcus sign downward traction sulcus below downward traction sulcus below
on arm on arm acromion=inferior laxity acromion=inferior laxity
ExamExam Technique Technique Significance Significance
Crossed Chest,Crossed Chest, Passive forward flex pain= AC pathology Passive forward flex pain= AC pathology
Adduction testAdduction test to 90 & adductionto 90 & adduction
Acromioclavicular same after AC lido inj relief of pain= AC Acromioclavicular same after AC lido inj relief of pain= AC
path path
InjectionInjection
Yergason testYergason test resisted supination pain= bicipital resisted supination pain= bicipital tendonitistendonitis
Lift off signLift off sign arm behind back lifted arm behind back lifted inability to accomplish inability to accomplish
posteriorlyposteriorly = subscapularis tear = subscapularis tear
Wrights testWrights test extension, abduction, extension, abduction, loss of pulse, loss of pulse,
external rotation of arm, reproduction of sympexternal rotation of arm, reproduction of symp
neck rotated awayneck rotated away = thoracic outlet synd = thoracic outlet synd
Crossed Chest,Crossed Chest, Passive forward flex pain= AC pathology Passive forward flex pain= AC pathology
Adduction testAdduction test to 90 & adductionto 90 & adduction
Acromioclavicular same after AC lido inj relief of pain= AC Acromioclavicular same after AC lido inj relief of pain= AC
path path
InjectionInjection
Yergason testYergason test resisted supination pain= bicipital resisted supination pain= bicipital tendonitistendonitis
Lift off signLift off sign arm behind back lifted arm behind back lifted inability to accomplish inability to accomplish
posteriorlyposteriorly = subscapularis tear = subscapularis tear
Wrights testWrights test extension, abduction, extension, abduction, loss of pulse, loss of pulse,
external rotation of arm, reproduction of sympexternal rotation of arm, reproduction of symp
neck rotated awayneck rotated away = thoracic outlet synd = thoracic outlet synd
Anterior Glenohumeral Dislocation Anterior Glenohumeral Dislocation
“Shoulder dislocation”“Shoulder dislocation”
Mechanism of injury:Mechanism of injury:
From From external rotation or abduction force on humerusexternal rotation or abduction force on humerus
From a direct posterior blow to proximal humerusFrom a direct posterior blow to proximal humerus
From a posterolateral blow on the shoulderFrom a posterolateral blow on the shoulder
Exam:Exam:
Space underneath acromion where humeral head should Space underneath acromion where humeral head should
lielie
Palpable anterior mass representing humeral head in Palpable anterior mass representing humeral head in
anterior axillaanterior axilla
Tx:Tx:
Closed reductionClosed reduction
Immobilization in internal rotationImmobilization in internal rotation
“Shoulder dislocation”“Shoulder dislocation”
Mechanism of injury:Mechanism of injury:
From From external rotation or abduction force on humerusexternal rotation or abduction force on humerus
From a direct posterior blow to proximal humerusFrom a direct posterior blow to proximal humerus
From a posterolateral blow on the shoulderFrom a posterolateral blow on the shoulder
Exam:Exam:
Space underneath acromion where humeral head should Space underneath acromion where humeral head should
lielie
Palpable anterior mass representing humeral head in Palpable anterior mass representing humeral head in
anterior axillaanterior axilla
Tx:Tx:
Closed reductionClosed reduction
Immobilization in internal rotationImmobilization in internal rotation
Types of closed reductionTypes of closed reduction
Stimson maneuver:Stimson maneuver:
Pt prone on table with weight on armPt prone on table with weight on arm
Mitch maneuver:Mitch maneuver:
Pt supine, steady downward traction applied at elbow, Pt supine, steady downward traction applied at elbow,
combined with slow gradual external rotation and combined with slow gradual external rotation and
abduction of limbabduction of limb
Hippocratic maneuver:Hippocratic maneuver:
Pt supine, examiner places sole of foot in axilla (shoe Pt supine, examiner places sole of foot in axilla (shoe
removed), grabs pt’s wrist with both hands and applies removed), grabs pt’s wrist with both hands and applies
steady longitudinal tractionsteady longitudinal traction
Traction/ countertraction:Traction/ countertraction:
Sheet method 2 people opposingSheet method 2 people opposing
Scapular manipulationScapular manipulation
Stimson maneuver with medial manipulation of tip of Stimson maneuver with medial manipulation of tip of
scapulascapula
Stimson maneuver:Stimson maneuver:
Pt prone on table with weight on armPt prone on table with weight on arm
Mitch maneuver:Mitch maneuver:
Pt supine, steady downward traction applied at elbow, Pt supine, steady downward traction applied at elbow,
combined with slow gradual external rotation and combined with slow gradual external rotation and
abduction of limbabduction of limb
Hippocratic maneuver:Hippocratic maneuver:
Pt supine, examiner places sole of foot in axilla (shoe Pt supine, examiner places sole of foot in axilla (shoe
removed), grabs pt’s wrist with both hands and applies removed), grabs pt’s wrist with both hands and applies
steady longitudinal tractionsteady longitudinal traction
Traction/ countertraction:Traction/ countertraction:
Sheet method 2 people opposingSheet method 2 people opposing
Scapular manipulationScapular manipulation
Stimson maneuver with medial manipulation of tip of Stimson maneuver with medial manipulation of tip of
scapulascapula
Anterior Glenohumeral DislocationAnterior Glenohumeral Dislocation
2 lesions with recurrent dislocations:2 lesions with recurrent dislocations:
Bankhart Lesion:Bankhart Lesion:
Anterior capsular injury assoc with a tear of the Anterior capsular injury assoc with a tear of the
glenoid labrum off the anterior glenoid rimglenoid labrum off the anterior glenoid rim
Hill-Sachs Lesion:Hill-Sachs Lesion:
Compression fracture of the articular surface of Compression fracture of the articular surface of
the humeral head posterolaterlaterally that is the humeral head posterolaterlaterally that is
created by the sharp edge of the anterior glenoid created by the sharp edge of the anterior glenoid
as the humeral head dislocates over itas the humeral head dislocates over it
2 lesions with recurrent dislocations:2 lesions with recurrent dislocations:
Bankhart Lesion:Bankhart Lesion:
Anterior capsular injury assoc with a tear of the Anterior capsular injury assoc with a tear of the
glenoid labrum off the anterior glenoid rimglenoid labrum off the anterior glenoid rim
Hill-Sachs Lesion:Hill-Sachs Lesion:
Compression fracture of the articular surface of Compression fracture of the articular surface of
the humeral head posterolaterlaterally that is the humeral head posterolaterlaterally that is
created by the sharp edge of the anterior glenoid created by the sharp edge of the anterior glenoid
as the humeral head dislocates over itas the humeral head dislocates over it
Glenoid Labrum InjuryGlenoid Labrum Injury
From repeated anterior subluxation of the From repeated anterior subluxation of the
shouldershoulder
From anterior instability during acceleration From anterior instability during acceleration
phase of throwing secondary to long head of phase of throwing secondary to long head of
biceps pulling on anterior labrumbiceps pulling on anterior labrum
From repetitive bench pressing and overhead From repetitive bench pressing and overhead
pressingpressing
From fall on outstretched armFrom fall on outstretched arm
From repeated anterior subluxation of the From repeated anterior subluxation of the
shouldershoulder
From anterior instability during acceleration From anterior instability during acceleration
phase of throwing secondary to long head of phase of throwing secondary to long head of
biceps pulling on anterior labrumbiceps pulling on anterior labrum
From repetitive bench pressing and overhead From repetitive bench pressing and overhead
pressingpressing
From fall on outstretched armFrom fall on outstretched arm
Glenoid Labrum InjuryGlenoid Labrum Injury
Patient c/o pain that interrupts smooth Patient c/o pain that interrupts smooth
functioning of shoulder during performance of functioning of shoulder during performance of
specific activityspecific activity
Exam:Exam:
Pain on forced external rotation @ 90 degrees Pain on forced external rotation @ 90 degrees
abductionabduction
““pop” or “click” on forced external rotationpop” or “click” on forced external rotation
Weakness of rotator cuff musclesWeakness of rotator cuff muscles
CT scan or MRI with contrast may allow early CT scan or MRI with contrast may allow early
detectiondetection
Tx:Tx:
Physical therapyPhysical therapy
Arthroscopic repairArthroscopic repair
Patient c/o pain that interrupts smooth Patient c/o pain that interrupts smooth
functioning of shoulder during performance of functioning of shoulder during performance of
specific activityspecific activity
Exam:Exam:
Pain on forced external rotation @ 90 degrees Pain on forced external rotation @ 90 degrees
abductionabduction
““pop” or “click” on forced external rotationpop” or “click” on forced external rotation
Weakness of rotator cuff musclesWeakness of rotator cuff muscles
CT scan or MRI with contrast may allow early CT scan or MRI with contrast may allow early
detectiondetection
Tx:Tx:
Physical therapyPhysical therapy
Arthroscopic repairArthroscopic repair
Rotator CuffRotator Cuff
The rotator cuff connects the humerus to The rotator cuff connects the humerus to
the scapula. the scapula.
The rotator cuff is formed by the tendons The rotator cuff is formed by the tendons
of four muscles: of four muscles:
the the supraspinatus, supraspinatus,
infraspinatus, infraspinatus,
teres minor,teres minor, and and
subscapularis.subscapularis.
The rotator cuff connects the humerus to The rotator cuff connects the humerus to
the scapula. the scapula.
The rotator cuff is formed by the tendons The rotator cuff is formed by the tendons
of four muscles: of four muscles:
the the supraspinatus, supraspinatus,
infraspinatus, infraspinatus,
teres minor,teres minor, and and
subscapularis.subscapularis.
BursitisBursitis
BursitisBursitis
Bursitis is defined as inflammation of a bursa. Bursitis is defined as inflammation of a bursa.
Bursae are closed, round, flattened sacs that are lined by synovium and separate bare 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 areas of bone from overlapping muscles (deep bursae) or skin and tendons (superficial
bursae). bursae).
They occur at areas of friction or possible impingement. They occur at areas of friction or possible impingement.
Bursae function to reduce friction and allow a greater range of movement when muscle Bursae function to reduce friction and allow a greater range of movement when muscle
contracts. contracts.
They may or may not communicate with the adjacent joint space. Symptoms of bursitis 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 include inflammation, localized tenderness, warmth, edema, erythema of the skin (if
superficial), and loss of function superficial), and loss of function
When inflamed, the synovial cells increase in thickness and may show villous When inflamed, the synovial cells increase in thickness and may show villous
hyperplasia. hyperplasia.
Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue
formation. formation.
The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage
sometimes occurs. sometimes occurs.
Patients often complain of a dull shoulder ache. Patients often complain of a dull shoulder ache.
The most common symptom of subacromial bursitis is tenderness over the greater 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. trochanter (and beneath the deltoid muscle) that disappears when the arm is abducted.
Bursitis is defined as inflammation of a bursa. Bursitis is defined as inflammation of a bursa.
Bursae are closed, round, flattened sacs that are lined by synovium and separate bare 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 areas of bone from overlapping muscles (deep bursae) or skin and tendons (superficial
bursae). bursae).
They occur at areas of friction or possible impingement. They occur at areas of friction or possible impingement.
Bursae function to reduce friction and allow a greater range of movement when muscle Bursae function to reduce friction and allow a greater range of movement when muscle
contracts. contracts.
They may or may not communicate with the adjacent joint space. Symptoms of bursitis 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 include inflammation, localized tenderness, warmth, edema, erythema of the skin (if
superficial), and loss of function superficial), and loss of function
When inflamed, the synovial cells increase in thickness and may show villous When inflamed, the synovial cells increase in thickness and may show villous
hyperplasia. hyperplasia.
Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue
formation. formation.
The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage
sometimes occurs. sometimes occurs.
Patients often complain of a dull shoulder ache. Patients often complain of a dull shoulder ache.
The most common symptom of subacromial bursitis is tenderness over the greater 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. trochanter (and beneath the deltoid muscle) that disappears when the arm is abducted.
Clavicle fractureClavicle fracture
Most common bone fracturedMost common bone fractured
The weakest part being the junction of the middle and lateral thirdsThe weakest part being the junction of the middle and lateral thirds
Class A (middle third fractures) (80%): Class A (middle third fractures) (80%):
Treat with sling immobilization. Treat with sling immobilization.
Some prefer using a figure-eight clavicular splint, especially for displaced Some prefer using a figure-eight clavicular splint, especially for displaced
fractures.fractures.
Class B (distal third fractures) (15%): Class B (distal third fractures) (15%):
Treat type I (nondisplaced) and type III (articular surface) fractures with sling Treat type I (nondisplaced) and type III (articular surface) fractures with sling
immobilization. immobilization.
Immobilize type II (displaced) fractures in a sling and swathe. Immobilize type II (displaced) fractures in a sling and swathe.
These may require orthopedic surgical fixation.These may require orthopedic surgical fixation.
Class C (proximal third) (5%): Class C (proximal third) (5%):
Treat nondisplaced fractures with sling immobilization. Treat nondisplaced fractures with sling immobilization.
Displaced injuries may require orthopedic referral for surgical reduction. Displaced injuries may require orthopedic referral for surgical reduction.
Neonatal fractures generally heal spontaneously in several weeks without special Neonatal fractures generally heal spontaneously in several weeks without special
treatment.treatment.
Most common bone fracturedMost common bone fractured
The weakest part being the junction of the middle and lateral thirdsThe weakest part being the junction of the middle and lateral thirds
Class A (middle third fractures) (80%): Class A (middle third fractures) (80%):
Treat with sling immobilization. Treat with sling immobilization.
Some prefer using a figure-eight clavicular splint, especially for displaced Some prefer using a figure-eight clavicular splint, especially for displaced
fractures.fractures.
Class B (distal third fractures) (15%): Class B (distal third fractures) (15%):
Treat type I (nondisplaced) and type III (articular surface) fractures with sling Treat type I (nondisplaced) and type III (articular surface) fractures with sling
immobilization. immobilization.
Immobilize type II (displaced) fractures in a sling and swathe. Immobilize type II (displaced) fractures in a sling and swathe.
These may require orthopedic surgical fixation.These may require orthopedic surgical fixation.
Class C (proximal third) (5%): Class C (proximal third) (5%):
Treat nondisplaced fractures with sling immobilization. Treat nondisplaced fractures with sling immobilization.
Displaced injuries may require orthopedic referral for surgical reduction. Displaced injuries may require orthopedic referral for surgical reduction.
Neonatal fractures generally heal spontaneously in several weeks without special Neonatal fractures generally heal spontaneously in several weeks without special
treatment.treatment.
Normal-----Normal-----
----------NormalNormal
FRACTUREFRACTURE--------
----------NormalNormal
FRACTUREFRACTURE--------
Acromio-clavicular Acromio-clavicular
(AC) separation (AC) separation
(separated shoulder)(separated shoulder)
Mechanism of injury- Mechanism of injury- fall onto point of shoulderfall onto point of shoulder
If there has been significant disruption (or a fracture to the If there has been significant disruption (or a fracture to the
clavicle itself), the area will appear swollen and deformed clavicle itself), the area will appear swollen and deformed
compared with the other side. compared with the other side.
The patient will avoid movement, do to pain. The patient will avoid movement, do to pain.
Gently have the patient move their arm across their chest Gently have the patient move their arm across their chest
while you palpate in the AC region. while you palpate in the AC region.
This will cause pain specifically at the AC joint if there is separation. This will cause pain specifically at the AC joint if there is separation.
Tenderness is felt at the junction, or the site of the AC Tenderness is felt at the junction, or the site of the AC
(acromioclavicular) joint(acromioclavicular) joint. .
(AC) separation (AC) separation
(separated shoulder)(separated shoulder)
Mechanism of injury- Mechanism of injury- fall onto point of shoulderfall onto point of shoulder
If there has been significant disruption (or a fracture to the If there has been significant disruption (or a fracture to the
clavicle itself), the area will appear swollen and deformed clavicle itself), the area will appear swollen and deformed
compared with the other side. compared with the other side.
The patient will avoid movement, do to pain. The patient will avoid movement, do to pain.
Gently have the patient move their arm across their chest Gently have the patient move their arm across their chest
while you palpate in the AC region. while you palpate in the AC region.
This will cause pain specifically at the AC joint if there is separation. This will cause pain specifically at the AC joint if there is separation.
Tenderness is felt at the junction, or the site of the AC Tenderness is felt at the junction, or the site of the AC
(acromioclavicular) joint(acromioclavicular) joint. .
Paralysis of the Serratus AnteriorParalysis of the Serratus Anterior
Results from injury to the Results from injury to the long thoracic nervelong thoracic nerve
causing causing a a “Winging of the Scapula”“Winging of the Scapula”
Results from injury to the Results from injury to the long thoracic nervelong thoracic nerve
causing causing a a “Winging of the Scapula”“Winging of the Scapula”
II
TT
AA
LL
YY
TREVI FOUNTAIN ROMATREVI FOUNTAIN ROMA
FONTANA DI TREVIFONTANA DI TREVI
TT
AA
LL
YY
TREVI FOUNTAIN ROMATREVI FOUNTAIN ROMA
FONTANA DI TREVIFONTANA DI TREVI
Brachial Plexus InjuriesBrachial Plexus Injuries
Disease, stretching, and wounds in the posterior triangle of Disease, stretching, and wounds in the posterior triangle of
the neckthe neck
Injuries to the brachial plexus result in paralysis and Injuries to the brachial plexus result in paralysis and
anesthesia.anesthesia.
Superior trunk injuries Superior trunk injuries (C5-6):(C5-6): “Waiter’s tip“Waiter’s tip” ” position (Erb-position (Erb-
Duchenne palsy) Duchenne palsy)
Fall (motorcycle), newborn forced delivery (stretched neck), heavy Fall (motorcycle), newborn forced delivery (stretched neck), heavy
backpacks backpacks
Inferior injuries Inferior injuries (C8-T1(C8-T1): ): “Claw hand”“Claw hand” (Klumpke paralysis)(Klumpke paralysis)
Arm jerked superiorly, grabbing tree branch while falling, pulling Arm jerked superiorly, grabbing tree branch while falling, pulling
on baby’s upper ext during childbirth.on baby’s upper ext during childbirth.
Disease, stretching, and wounds in the posterior triangle of Disease, stretching, and wounds in the posterior triangle of
the neckthe neck
Injuries to the brachial plexus result in paralysis and Injuries to the brachial plexus result in paralysis and
anesthesia.anesthesia.
Superior trunk injuries Superior trunk injuries (C5-6):(C5-6): “Waiter’s tip“Waiter’s tip” ” position (Erb-position (Erb-
Duchenne palsy) Duchenne palsy)
Fall (motorcycle), newborn forced delivery (stretched neck), heavy Fall (motorcycle), newborn forced delivery (stretched neck), heavy
backpacks backpacks
Inferior injuries Inferior injuries (C8-T1(C8-T1): ): “Claw hand”“Claw hand” (Klumpke paralysis)(Klumpke paralysis)
Arm jerked superiorly, grabbing tree branch while falling, pulling Arm jerked superiorly, grabbing tree branch while falling, pulling
on baby’s upper ext during childbirth.on baby’s upper ext during childbirth.
Bicipital TendonitisBicipital Tendonitis
Pain localized to proximal humerus and Pain localized to proximal humerus and
shoulder joint, with resistive supination of shoulder joint, with resistive supination of
the forearm aggravating symptomsthe forearm aggravating symptoms
+ Yergason test+ Yergason test (resisted supination) for (resisted supination) for
unstable long head of biceps in bicipital unstable long head of biceps in bicipital
groovegroove
Tx:Tx:
Physical therapyPhysical therapy
Activity modificationActivity modification
NSAID’sNSAID’s
Pain localized to proximal humerus and Pain localized to proximal humerus and
shoulder joint, with resistive supination of shoulder joint, with resistive supination of
the forearm aggravating symptomsthe forearm aggravating symptoms
+ Yergason test+ Yergason test (resisted supination) for (resisted supination) for
unstable long head of biceps in bicipital unstable long head of biceps in bicipital
groovegroove
Tx:Tx:
Physical therapyPhysical therapy
Activity modificationActivity modification
NSAID’sNSAID’s
Shoulder FracturesShoulder Fractures
Proximal Humerus Fractures:Proximal Humerus Fractures:
Neer classificaton:Neer classificaton:
Non-displaced fractures: Non-displaced fractures:
are displaced less than 1cm or angulated <45 degrees, regardless of the are displaced less than 1cm or angulated <45 degrees, regardless of the
fracture pattern or # of fragmentsfracture pattern or # of fragments
Displaced fractures:Displaced fractures:
2 part2 part fx’s are fractured either through the anatomical neck, surgical neck, fx’s are fractured either through the anatomical neck, surgical neck,
greater tuberosity or lesser tuberositygreater tuberosity or lesser tuberosity
3 part3 part fx’s are fx’s of the surgical neck with fractures of either the greater fx’s are fx’s of the surgical neck with fractures of either the greater
tuberosity or lesser tuberositytuberosity or lesser tuberosity
4 part4 part fx’s are fxs of the anatomic neck & fractures of the greater and fx’s are fxs of the anatomic neck & fractures of the greater and
lesser tuberositieslesser tuberosities
Proximal Humerus Fractures:Proximal Humerus Fractures:
Neer classificaton:Neer classificaton:
Non-displaced fractures: Non-displaced fractures:
are displaced less than 1cm or angulated <45 degrees, regardless of the are displaced less than 1cm or angulated <45 degrees, regardless of the
fracture pattern or # of fragmentsfracture pattern or # of fragments
Displaced fractures:Displaced fractures:
2 part2 part fx’s are fractured either through the anatomical neck, surgical neck, fx’s are fractured either through the anatomical neck, surgical neck,
greater tuberosity or lesser tuberositygreater tuberosity or lesser tuberosity
3 part3 part fx’s are fx’s of the surgical neck with fractures of either the greater fx’s are fx’s of the surgical neck with fractures of either the greater
tuberosity or lesser tuberositytuberosity or lesser tuberosity
4 part4 part fx’s are fxs of the anatomic neck & fractures of the greater and fx’s are fxs of the anatomic neck & fractures of the greater and
lesser tuberositieslesser tuberosities
Humeral FracturesHumeral Fractures
Neurovascular status must be evaluated Neurovascular status must be evaluated
with fractureswith fractures
The humerus is in direct contact with The humerus is in direct contact with
nerves that can be injured due to a fracture.nerves that can be injured due to a fracture.
Surgical neckSurgical neck: axillary nerve : axillary nerve (C5-6, deltoid (C5-6, deltoid
atrophy) (also from improper crutch use atrophy) (also from improper crutch use
“waiter’s tip”)“waiter’s tip”)
Radial groove: Radial groove: radial nerveradial nerve
Distal end of humerusDistal end of humerus: median nerve: median nerve
Medial epicondyle: Medial epicondyle: ulnar nerveulnar nerve
Neurovascular status must be evaluated Neurovascular status must be evaluated
with fractureswith fractures
The humerus is in direct contact with The humerus is in direct contact with
nerves that can be injured due to a fracture.nerves that can be injured due to a fracture.
Surgical neckSurgical neck: axillary nerve : axillary nerve (C5-6, deltoid (C5-6, deltoid
atrophy) (also from improper crutch use atrophy) (also from improper crutch use
“waiter’s tip”)“waiter’s tip”)
Radial groove: Radial groove: radial nerveradial nerve
Distal end of humerusDistal end of humerus: median nerve: median nerve
Medial epicondyle: Medial epicondyle: ulnar nerveulnar nerve
Proximal Humerus FractureProximal Humerus Fracture
The vascularity is at risk with anatomical neck The vascularity is at risk with anatomical neck
fracturesfractures
Most common mechanism of injury= FOOSHMost common mechanism of injury= FOOSH
Signs & symptoms:Signs & symptoms:
Pain, swelling, tenderness Pain, swelling, tenderness
Tx:Tx:
For nondisplaced fx’s= sling, begin ROM exercisesFor nondisplaced fx’s= sling, begin ROM exercises
2 part/3 part fx’s= closed reduction, sling, possible 2 part/3 part fx’s= closed reduction, sling, possible
ORIFORIF
Absolute indication for hemi-arthroplasty: 4 part fx’s, Absolute indication for hemi-arthroplasty: 4 part fx’s,
non-reducible 3 part fx’snon-reducible 3 part fx’s
FOOSH = Fall On Outstretched HandFOOSH = Fall On Outstretched Hand
The vascularity is at risk with anatomical neck The vascularity is at risk with anatomical neck
fracturesfractures
Most common mechanism of injury= FOOSHMost common mechanism of injury= FOOSH
Signs & symptoms:Signs & symptoms:
Pain, swelling, tenderness Pain, swelling, tenderness
Tx:Tx:
For nondisplaced fx’s= sling, begin ROM exercisesFor nondisplaced fx’s= sling, begin ROM exercises
2 part/3 part fx’s= closed reduction, sling, possible 2 part/3 part fx’s= closed reduction, sling, possible
ORIFORIF
Absolute indication for hemi-arthroplasty: 4 part fx’s, Absolute indication for hemi-arthroplasty: 4 part fx’s,
non-reducible 3 part fx’snon-reducible 3 part fx’s
FOOSH = Fall On Outstretched HandFOOSH = Fall On Outstretched Hand
Midshaft Humerus FracturesMidshaft Humerus Fractures
Signs & Symptoms:Signs & Symptoms:
Arm pain, swelling, deformityArm pain, swelling, deformity
The arm is shortened with gross motion & crepitus on The arm is shortened with gross motion & crepitus on
gentle manipulationgentle manipulation
XR:XR:
AP/lat c shoulder & elbowAP/lat c shoulder & elbow
Tx:Tx:
Coaptation splintCoaptation splint
Carefully molded plaster slab placed around medial & lateral Carefully molded plaster slab placed around medial & lateral
aspects of arm, extending from axilla around elbow & over aspects of arm, extending from axilla around elbow & over
deltoid & acromion x 2 wksdeltoid & acromion x 2 wks
Change to Sarmiento brace @ 2 wksChange to Sarmiento brace @ 2 wks
May require ORIF with plate/screw or intramedullary May require ORIF with plate/screw or intramedullary
nailingnailing
Signs & Symptoms:Signs & Symptoms:
Arm pain, swelling, deformityArm pain, swelling, deformity
The arm is shortened with gross motion & crepitus on The arm is shortened with gross motion & crepitus on
gentle manipulationgentle manipulation
XR:XR:
AP/lat c shoulder & elbowAP/lat c shoulder & elbow
Tx:Tx:
Coaptation splintCoaptation splint
Carefully molded plaster slab placed around medial & lateral Carefully molded plaster slab placed around medial & lateral
aspects of arm, extending from axilla around elbow & over aspects of arm, extending from axilla around elbow & over
deltoid & acromion x 2 wksdeltoid & acromion x 2 wks
Change to Sarmiento brace @ 2 wksChange to Sarmiento brace @ 2 wks
May require ORIF with plate/screw or intramedullary May require ORIF with plate/screw or intramedullary
nailingnailing
Midshaft humerus fxMidshaft humerus fx
Distal Humerus FractureDistal Humerus Fracture
Supracondylar fx’s of the Humerus:Supracondylar fx’s of the Humerus:
Characterized by dissociation b/t diaphysis & condyles of Characterized by dissociation b/t diaphysis & condyles of
distal humerus, frequently extended distally & involves distal humerus, frequently extended distally & involves
articular surfacearticular surface
Caused by FOOSH or direct blowCaused by FOOSH or direct blow
PE:PE:
+ deformity, instability, crepitus+ deformity, instability, crepitus
XR:XR:
AP/lat/obliqAP/lat/obliq
Management:Management:
Initial: alignment, immobilization, ice, long arm splintInitial: alignment, immobilization, ice, long arm splint
Definitive: ORIF, early motionDefinitive: ORIF, early motion
(Other fx’s: transcondylar, medial condyle, lateral (Other fx’s: transcondylar, medial condyle, lateral
condyle)condyle)
Supracondylar fx’s of the Humerus:Supracondylar fx’s of the Humerus:
Characterized by dissociation b/t diaphysis & condyles of Characterized by dissociation b/t diaphysis & condyles of
distal humerus, frequently extended distally & involves distal humerus, frequently extended distally & involves
articular surfacearticular surface
Caused by FOOSH or direct blowCaused by FOOSH or direct blow
PE:PE:
+ deformity, instability, crepitus+ deformity, instability, crepitus
XR:XR:
AP/lat/obliqAP/lat/obliq
Management:Management:
Initial: alignment, immobilization, ice, long arm splintInitial: alignment, immobilization, ice, long arm splint
Definitive: ORIF, early motionDefinitive: ORIF, early motion
(Other fx’s: transcondylar, medial condyle, lateral (Other fx’s: transcondylar, medial condyle, lateral
condyle)condyle)
MONTMARTREMONTMARTRE
PARISPARIS
FRANCEFRANCE
PARISPARIS
FRANCEFRANCE
Radial Head FractureRadial Head Fracture
MOI:MOI:
Fall forward with elbow extended, forearm pronatedFall forward with elbow extended, forearm pronated
Pain localized to radial headPain localized to radial head
XR:XR:
AP/lat/obliqAP/lat/obliq
TX:TX:
Types I, II, & III without mechanical block are treated Types I, II, & III without mechanical block are treated
with a sling and AROM x 3 wkswith a sling and AROM x 3 wks
After 3 wks d/c sling & begin aggressive PTAfter 3 wks d/c sling & begin aggressive PT
Fx’s with elbow instability or mechanical block are treated Fx’s with elbow instability or mechanical block are treated
operatively with either reduction & fixation of head, operatively with either reduction & fixation of head,
excision of head, or ligament repairexcision of head, or ligament repair
MOI:MOI:
Fall forward with elbow extended, forearm pronatedFall forward with elbow extended, forearm pronated
Pain localized to radial headPain localized to radial head
XR:XR:
AP/lat/obliqAP/lat/obliq
TX:TX:
Types I, II, & III without mechanical block are treated Types I, II, & III without mechanical block are treated
with a sling and AROM x 3 wkswith a sling and AROM x 3 wks
After 3 wks d/c sling & begin aggressive PTAfter 3 wks d/c sling & begin aggressive PT
Fx’s with elbow instability or mechanical block are treated Fx’s with elbow instability or mechanical block are treated
operatively with either reduction & fixation of head, operatively with either reduction & fixation of head,
excision of head, or ligament repairexcision of head, or ligament repair
Olecranon FracturesOlecranon Fractures
Pain @ elbow with h/o traumaPain @ elbow with h/o trauma
XR:XR:
AP/lat/obliqAP/lat/obliq
ManagementManagement
Initial: sling for comfortInitial: sling for comfort
Definitive: Definitive:
non-displaced fx’s can be managed with non-displaced fx’s can be managed with
posterior splint @ 90 degrees flexion x 2 wksposterior splint @ 90 degrees flexion x 2 wks
Other fx’s are managed with ORIF or Other fx’s are managed with ORIF or
percutaneous pinning & early motion post-percutaneous pinning & early motion post-
operativelyoperatively
Pain @ elbow with h/o traumaPain @ elbow with h/o trauma
XR:XR:
AP/lat/obliqAP/lat/obliq
ManagementManagement
Initial: sling for comfortInitial: sling for comfort
Definitive: Definitive:
non-displaced fx’s can be managed with non-displaced fx’s can be managed with
posterior splint @ 90 degrees flexion x 2 wksposterior splint @ 90 degrees flexion x 2 wks
Other fx’s are managed with ORIF or Other fx’s are managed with ORIF or
percutaneous pinning & early motion post-percutaneous pinning & early motion post-
operativelyoperatively
Nursemaid’s ElbowNursemaid’s Elbow
Subluxation of the radial head from the Annular Subluxation of the radial head from the Annular
ligamentligament
MC from sudden jerking of child’s hand while in MC from sudden jerking of child’s hand while in
pronationpronation
Subluxation of the radial head from the Annular Subluxation of the radial head from the Annular
ligamentligament
MC from sudden jerking of child’s hand while in MC from sudden jerking of child’s hand while in
pronationpronation
Elbow FracturesElbow Fractures
Monteggia FractureMonteggia Fracture
Usually a fx of Usually a fx of the the mid or proximal ulna with mid or proximal ulna with
anterior dislocation of the radial headanterior dislocation of the radial head
MOI:MOI:
Forceful pronation or direct blow to dorsum of ulnaForceful pronation or direct blow to dorsum of ulna
H&P:H&P:
Pain & h/o trauma, may have obvious deformityPain & h/o trauma, may have obvious deformity
XR:XR:
AP/lat/obliqAP/lat/obliq
TX:TX:
Hematoma block, reduction, long arm cast or splintHematoma block, reduction, long arm cast or splint
May require ORIFMay require ORIF
Monteggia FractureMonteggia Fracture
Usually a fx of Usually a fx of the the mid or proximal ulna with mid or proximal ulna with
anterior dislocation of the radial headanterior dislocation of the radial head
MOI:MOI:
Forceful pronation or direct blow to dorsum of ulnaForceful pronation or direct blow to dorsum of ulna
H&P:H&P:
Pain & h/o trauma, may have obvious deformityPain & h/o trauma, may have obvious deformity
XR:XR:
AP/lat/obliqAP/lat/obliq
TX:TX:
Hematoma block, reduction, long arm cast or splintHematoma block, reduction, long arm cast or splint
May require ORIFMay require ORIF
Galeazzi Fracture/dislocationGaleazzi Fracture/dislocation
An injury pattern involving a An injury pattern involving a radial shaft fracture with radial shaft fracture with
associated dislocation of the distal radioulnar jointassociated dislocation of the distal radioulnar joint
(DRUJ), which disrupts the forearm axis joint. (DRUJ), which disrupts the forearm axis joint.
"fracture of necessity" "fracture of necessity" refers to the adult Galeazzi refers to the adult Galeazzi
fracture not being amenable to treatment by closed fracture not being amenable to treatment by closed
means, necessitating surgical stabilization. means, necessitating surgical stabilization.
An injury pattern involving a An injury pattern involving a radial shaft fracture with radial shaft fracture with
associated dislocation of the distal radioulnar jointassociated dislocation of the distal radioulnar joint
(DRUJ), which disrupts the forearm axis joint. (DRUJ), which disrupts the forearm axis joint.
"fracture of necessity" "fracture of necessity" refers to the adult Galeazzi refers to the adult Galeazzi
fracture not being amenable to treatment by closed fracture not being amenable to treatment by closed
means, necessitating surgical stabilization. means, necessitating surgical stabilization.
Galeazzi Galeazzi
(Reverse Monteggia)(Reverse Monteggia)
(Reverse Monteggia)(Reverse Monteggia)
SAN CARLOS DE BARILOCHESAN CARLOS DE BARILOCHE
ARGENTINAARGENTINA
ARGENTINAARGENTINA
Lateral Epicondylitis (Tennis Elbow)Lateral Epicondylitis (Tennis Elbow)
Pain at lateral humeral epicondyle, Pain at lateral humeral epicondyle,
reproduced by extending the wrist reproduced by extending the wrist
against resistanceagainst resistance
Seen in patients who perform repetitive Seen in patients who perform repetitive
wrist extension (Tennis)wrist extension (Tennis)
Tx:Tx:
NSAID’s, Restriction band, Physical NSAID’s, Restriction band, Physical
therapy, lighter racquet, correction of therapy, lighter racquet, correction of
backhand strokebackhand stroke
Pain at lateral humeral epicondyle, Pain at lateral humeral epicondyle,
reproduced by extending the wrist reproduced by extending the wrist
against resistanceagainst resistance
Seen in patients who perform repetitive Seen in patients who perform repetitive
wrist extension (Tennis)wrist extension (Tennis)
Tx:Tx:
NSAID’s, Restriction band, Physical NSAID’s, Restriction band, Physical
therapy, lighter racquet, correction of therapy, lighter racquet, correction of
backhand strokebackhand stroke
Medial EpicondylitisMedial Epicondylitis
(Pitcher’s Elbow, Golfer’s)(Pitcher’s Elbow, Golfer’s)
Pain at medial humeral epicondylePain at medial humeral epicondyle
Seen in patients who golf, or perform throwing Seen in patients who golf, or perform throwing
sports, such as baseball, football, javelinsports, such as baseball, football, javelin
Tx:Tx:
NSAID’s, Physical therapyNSAID’s, Physical therapy
(Pitcher’s Elbow, Golfer’s)(Pitcher’s Elbow, Golfer’s)
Pain at medial humeral epicondylePain at medial humeral epicondyle
Seen in patients who golf, or perform throwing Seen in patients who golf, or perform throwing
sports, such as baseball, football, javelinsports, such as baseball, football, javelin
Tx:Tx:
NSAID’s, Physical therapyNSAID’s, Physical therapy
Movements at the wristMovements at the wrist
Radial deviation (abduction)Radial deviation (abduction)
Ulnar deviation (adduction)Ulnar deviation (adduction)
FlexionFlexion
ExtensionExtension
SupinationSupination
PronationPronation
Combination of all of the aboveCombination of all of the above
Radial deviation (abduction)Radial deviation (abduction)
Ulnar deviation (adduction)Ulnar deviation (adduction)
FlexionFlexion
ExtensionExtension
SupinationSupination
PronationPronation
Combination of all of the aboveCombination of all of the above
Distal Forearm FracturesDistal Forearm Fractures
1. Extension fractures: 1. Extension fractures:
Colles FractureColles Fracture
Extra-articular fx with Extra-articular fx with dorsal dorsal
displacement of distal radiusdisplacement of distal radius
MC fx of the wristMC fx of the wrist
Usually Usually 2° to FOOSH2° to FOOSH
Exam:Exam:
Silver fork deformitySilver fork deformity, swelling, , swelling,
decreased ROM secondary to paindecreased ROM secondary to pain
XR:XR:
AP/true lateral/obliq- radius will be AP/true lateral/obliq- radius will be
shortenedshortened
1. Extension fractures: 1. Extension fractures:
Colles FractureColles Fracture
Extra-articular fx with Extra-articular fx with dorsal dorsal
displacement of distal radiusdisplacement of distal radius
MC fx of the wristMC fx of the wrist
Usually Usually 2° to FOOSH2° to FOOSH
Exam:Exam:
Silver fork deformitySilver fork deformity, swelling, , swelling,
decreased ROM secondary to paindecreased ROM secondary to pain
XR:XR:
AP/true lateral/obliq- radius will be AP/true lateral/obliq- radius will be
shortenedshortened
Colles fx
Distal Forearm Fractures (cont)Distal Forearm Fractures (cont)
2. 2. Non-displaced Distal Radius Fx’sNon-displaced Distal Radius Fx’s
Require short arm cast (SAC) in neutral, ice, Require short arm cast (SAC) in neutral, ice,
elevation, NSAIDS, analgesiaelevation, NSAIDS, analgesia
3. 3. Other common fx’s:Other common fx’s:
Smith’s fxSmith’s fx
Reverse Colles fxReverse Colles fx
Fracture of the distal radius with palmar displacement of the Fracture of the distal radius with palmar displacement of the
distal fragment.distal fragment.
Die Punch FxDie Punch Fx
Intra-articular distal radius fx with impaction of the dorsal Intra-articular distal radius fx with impaction of the dorsal
aspect of the lunate fossaaspect of the lunate fossa
Barton’s FxBarton’s Fx
Displaced intra-articular lip fx of the distal radius Displaced intra-articular lip fx of the distal radius
May be assoc with carpal subluxationMay be assoc with carpal subluxation
May be dorsal or volar configurationMay be dorsal or volar configuration
Extends into radio-carpal jointExtends into radio-carpal joint
2. 2. Non-displaced Distal Radius Fx’sNon-displaced Distal Radius Fx’s
Require short arm cast (SAC) in neutral, ice, Require short arm cast (SAC) in neutral, ice,
elevation, NSAIDS, analgesiaelevation, NSAIDS, analgesia
3. 3. Other common fx’s:Other common fx’s:
Smith’s fxSmith’s fx
Reverse Colles fxReverse Colles fx
Fracture of the distal radius with palmar displacement of the Fracture of the distal radius with palmar displacement of the
distal fragment.distal fragment.
Die Punch FxDie Punch Fx
Intra-articular distal radius fx with impaction of the dorsal Intra-articular distal radius fx with impaction of the dorsal
aspect of the lunate fossaaspect of the lunate fossa
Barton’s FxBarton’s Fx
Displaced intra-articular lip fx of the distal radius Displaced intra-articular lip fx of the distal radius
May be assoc with carpal subluxationMay be assoc with carpal subluxation
May be dorsal or volar configurationMay be dorsal or volar configuration
Extends into radio-carpal jointExtends into radio-carpal joint
Non-displaced distal radius fxNon-displaced distal radius fx
Smith’s fxSmith’s fx
Die Punch FxDie Punch Fx
Barton’s FxBarton’s Fx
ROSETTE ROSETTE
OFOF
NOTRE DOMENOTRE DOME
PARISPARIS
FRANCEFRANCE
OFOF
NOTRE DOMENOTRE DOME
PARISPARIS
FRANCEFRANCE
Scaphoid FracturesScaphoid Fractures
MC fx’d carpal boneMC fx’d carpal bone
There is no direct blood supply to the There is no direct blood supply to the proximal portionproximal portion of the of the
scaphoidscaphoid
Therefore, scaphoid fx’s have a tendency to develop Therefore, scaphoid fx’s have a tendency to develop delayed delayed
union or union or avascular necrosisavascular necrosis
Remember the more proximal the fx line is in the scaphoid Remember the more proximal the fx line is in the scaphoid
injuries, the greater the likelyhood of avascular necrosisinjuries, the greater the likelyhood of avascular necrosis
Mechanism of injuryMechanism of injury
Forceful hyperextension of the wristForceful hyperextension of the wrist
MC fx’d carpal boneMC fx’d carpal bone
There is no direct blood supply to the There is no direct blood supply to the proximal portionproximal portion of the of the
scaphoidscaphoid
Therefore, scaphoid fx’s have a tendency to develop Therefore, scaphoid fx’s have a tendency to develop delayed delayed
union or union or avascular necrosisavascular necrosis
Remember the more proximal the fx line is in the scaphoid Remember the more proximal the fx line is in the scaphoid
injuries, the greater the likelyhood of avascular necrosisinjuries, the greater the likelyhood of avascular necrosis
Mechanism of injuryMechanism of injury
Forceful hyperextension of the wristForceful hyperextension of the wrist
Scaphoid FracturesScaphoid Fractures
Exam: Exam:
+ snuffbox tenderness+ snuffbox tenderness,,
radial deviation of wrist will probably elicit painradial deviation of wrist will probably elicit pain
XR:XR:
Obtain AP/lat/obliq/scaphoid viewsObtain AP/lat/obliq/scaphoid views
Plain x-ray may not demonstrate fx for up to 4 wksPlain x-ray may not demonstrate fx for up to 4 wks
If x-rays are still negative at 10-14 days & pt is symptomatic, obtain If x-rays are still negative at 10-14 days & pt is symptomatic, obtain
bone scan for definitive diagnosisbone scan for definitive diagnosis
Tx:Tx:
Initially in ER:Initially in ER:
Thumb spica (*always tx snuffbox tenderness, even if x-ray neg)Thumb spica (*always tx snuffbox tenderness, even if x-ray neg)
Definitive: Definitive:
Long arm thumb spica cast x 4-8 wks.Long arm thumb spica cast x 4-8 wks.
If scaphoid is displaced, may require ORIFIf scaphoid is displaced, may require ORIF
Exam: Exam:
+ snuffbox tenderness+ snuffbox tenderness,,
radial deviation of wrist will probably elicit painradial deviation of wrist will probably elicit pain
XR:XR:
Obtain AP/lat/obliq/scaphoid viewsObtain AP/lat/obliq/scaphoid views
Plain x-ray may not demonstrate fx for up to 4 wksPlain x-ray may not demonstrate fx for up to 4 wks
If x-rays are still negative at 10-14 days & pt is symptomatic, obtain If x-rays are still negative at 10-14 days & pt is symptomatic, obtain
bone scan for definitive diagnosisbone scan for definitive diagnosis
Tx:Tx:
Initially in ER:Initially in ER:
Thumb spica (*always tx snuffbox tenderness, even if x-ray neg)Thumb spica (*always tx snuffbox tenderness, even if x-ray neg)
Definitive: Definitive:
Long arm thumb spica cast x 4-8 wks.Long arm thumb spica cast x 4-8 wks.
If scaphoid is displaced, may require ORIFIf scaphoid is displaced, may require ORIF
A. ThumbA. Thumb
B. IndexB. Index
C. Middle fingerC. Middle finger
D. Ring fingerD. Ring finger
E. Little finger E. Little finger
I-V. Metacarpal bonesI-V. Metacarpal bones
1,4. Distal phalanx1,4. Distal phalanx
2. Middle phalanx2. Middle phalanx
3,5. Proximal phalanx3,5. Proximal phalanx
6. Sesamoid bones6. Sesamoid bones
7. Distal interphalangeal joint (DIP)7. Distal interphalangeal joint (DIP)
8. Proximal interphalangeal joint (PIP)8. Proximal interphalangeal joint (PIP)
9. Metacarpophalangeal joint (V.)9. Metacarpophalangeal joint (V.)
10. Carpometacarpal joints10. Carpometacarpal joints
11. Trapezium11. Trapezium
12. Trapezoid12. Trapezoid
13. Capitate13. Capitate
14. Hamate14. Hamate
15. Scaphoid15. Scaphoid
16. Lunate16. Lunate
17. Triquetrum17. Triquetrum
18. Pisiform 18. Pisiform
19. Radius 19. Radius
20. Ulna 20. Ulna
B. IndexB. Index
C. Middle fingerC. Middle finger
D. Ring fingerD. Ring finger
E. Little finger E. Little finger
I-V. Metacarpal bonesI-V. Metacarpal bones
1,4. Distal phalanx1,4. Distal phalanx
2. Middle phalanx2. Middle phalanx
3,5. Proximal phalanx3,5. Proximal phalanx
6. Sesamoid bones6. Sesamoid bones
7. Distal interphalangeal joint (DIP)7. Distal interphalangeal joint (DIP)
8. Proximal interphalangeal joint (PIP)8. Proximal interphalangeal joint (PIP)
9. Metacarpophalangeal joint (V.)9. Metacarpophalangeal joint (V.)
10. Carpometacarpal joints10. Carpometacarpal joints
11. Trapezium11. Trapezium
12. Trapezoid12. Trapezoid
13. Capitate13. Capitate
14. Hamate14. Hamate
15. Scaphoid15. Scaphoid
16. Lunate16. Lunate
17. Triquetrum17. Triquetrum
18. Pisiform 18. Pisiform
19. Radius 19. Radius
20. Ulna 20. Ulna
Metacarpal Neck FracturesMetacarpal Neck Fractures
Boxer’s fx :Boxer’s fx : Most frequently occur at the 5Most frequently occur at the 5
thth
metacarpal,metacarpal, as a result of a direct blow delivered to the as a result of a direct blow delivered to the
hand or by the hand to a solid (animate or inanimate) hand or by the hand to a solid (animate or inanimate)
object while the hand is held in a fist object while the hand is held in a fist
Boxer’s fx :Boxer’s fx : Most frequently occur at the 5Most frequently occur at the 5
thth
metacarpal,metacarpal, as a result of a direct blow delivered to the as a result of a direct blow delivered to the
hand or by the hand to a solid (animate or inanimate) hand or by the hand to a solid (animate or inanimate)
object while the hand is held in a fist object while the hand is held in a fist
Metacarpal Neck Fx’sMetacarpal Neck Fx’s
(Boxer’s fx) (Boxer’s fx)
Fractures with angulation <15 degrees should be Fractures with angulation <15 degrees should be
immobilized in an ulnar gutter splint encasing both immobilized in an ulnar gutter splint encasing both
the 4the 4
thth
& 5 & 5
thth
fingers with the mcp joint flexed as close fingers with the mcp joint flexed as close
to 90 degrees as possible & wrist held in slight to 90 degrees as possible & wrist held in slight
extensionextension
Fx’s with angulation >15 degrees &/or with rotational Fx’s with angulation >15 degrees &/or with rotational
deformity of the finger should be reduced & deformity of the finger should be reduced &
casted/splinted in the aforementioned positioncasted/splinted in the aforementioned position
Post reduction films should be obtainedPost reduction films should be obtained
Unstable fx’s or fx’s that are not reduced to an Unstable fx’s or fx’s that are not reduced to an
acceptable position may require percutaneous pinningacceptable position may require percutaneous pinning
(Boxer’s fx) (Boxer’s fx)
Fractures with angulation <15 degrees should be Fractures with angulation <15 degrees should be
immobilized in an ulnar gutter splint encasing both immobilized in an ulnar gutter splint encasing both
the 4the 4
thth
& 5 & 5
thth
fingers with the mcp joint flexed as close fingers with the mcp joint flexed as close
to 90 degrees as possible & wrist held in slight to 90 degrees as possible & wrist held in slight
extensionextension
Fx’s with angulation >15 degrees &/or with rotational Fx’s with angulation >15 degrees &/or with rotational
deformity of the finger should be reduced & deformity of the finger should be reduced &
casted/splinted in the aforementioned positioncasted/splinted in the aforementioned position
Post reduction films should be obtainedPost reduction films should be obtained
Unstable fx’s or fx’s that are not reduced to an Unstable fx’s or fx’s that are not reduced to an
acceptable position may require percutaneous pinningacceptable position may require percutaneous pinning
Boutonniere DeformityBoutonniere Deformity
Disruption of the central slip of the Extensor Digitorum Disruption of the central slip of the Extensor Digitorum
Communis tendon from its insertion at the dorsal base of the Communis tendon from its insertion at the dorsal base of the
middle phalanx that results in middle phalanx that results in
a a flexed PIP joint & hyperextended DIP joint flexed PIP joint & hyperextended DIP joint
The deformity may not be present at the time of injury & The deformity may not be present at the time of injury &
usually develops over 10-21 daysusually develops over 10-21 days
Tx:Tx:
1. Splint PIP joint into full extension with passive & active flexion of 1. Splint PIP joint into full extension with passive & active flexion of
DIP jointDIP joint
2. Insert K-wire to PIP joint to hold extension, 2. Insert K-wire to PIP joint to hold extension,
3. continue passive & active flexion at DIP joint3. continue passive & active flexion at DIP joint
4. direct tendon repair & splinting4. direct tendon repair & splinting
Disruption of the central slip of the Extensor Digitorum Disruption of the central slip of the Extensor Digitorum
Communis tendon from its insertion at the dorsal base of the Communis tendon from its insertion at the dorsal base of the
middle phalanx that results in middle phalanx that results in
a a flexed PIP joint & hyperextended DIP joint flexed PIP joint & hyperextended DIP joint
The deformity may not be present at the time of injury & The deformity may not be present at the time of injury &
usually develops over 10-21 daysusually develops over 10-21 days
Tx:Tx:
1. Splint PIP joint into full extension with passive & active flexion of 1. Splint PIP joint into full extension with passive & active flexion of
DIP jointDIP joint
2. Insert K-wire to PIP joint to hold extension, 2. Insert K-wire to PIP joint to hold extension,
3. continue passive & active flexion at DIP joint3. continue passive & active flexion at DIP joint
4. direct tendon repair & splinting4. direct tendon repair & splinting
Mallet FingerMallet Finger
Disruption of the extensor tendon over the Disruption of the extensor tendon over the
distal phalanx with distal phalanx with flexion at the DIP joint & flexion at the DIP joint &
extension or hyperextension at the PIP jointextension or hyperextension at the PIP joint
Tx:Tx:
1. splint with hyperextension of the DIP joint, 1. splint with hyperextension of the DIP joint,
flexion of the PIP jointflexion of the PIP joint
2. Hold with K-wire2. Hold with K-wire
3. Direct tendon repair & splinting3. Direct tendon repair & splinting
Disruption of the extensor tendon over the Disruption of the extensor tendon over the
distal phalanx with distal phalanx with flexion at the DIP joint & flexion at the DIP joint &
extension or hyperextension at the PIP jointextension or hyperextension at the PIP joint
Tx:Tx:
1. splint with hyperextension of the DIP joint, 1. splint with hyperextension of the DIP joint,
flexion of the PIP jointflexion of the PIP joint
2. Hold with K-wire2. Hold with K-wire
3. Direct tendon repair & splinting3. Direct tendon repair & splinting
Flexor TenosynovitisFlexor Tenosynovitis
Infection of the digital synovial sheaths.Infection of the digital synovial sheaths.
Usually confined to affected fingerUsually confined to affected finger
ExceptExcept in in pinky and thumbpinky and thumb, can spread to palm, and forearm, can spread to palm, and forearm
Diagnosis is made on four classic findingsDiagnosis is made on four classic findings..
1. tenderness over flexor tendon sheath1. tenderness over flexor tendon sheath
2. symmetric swelling of the finger (sausage 2. symmetric swelling of the finger (sausage
finger)finger)
3. pain with passive extension3. pain with passive extension
4. flexed posture of the involved digit at rest4. flexed posture of the involved digit at rest
Infection of the digital synovial sheaths.Infection of the digital synovial sheaths.
Usually confined to affected fingerUsually confined to affected finger
ExceptExcept in in pinky and thumbpinky and thumb, can spread to palm, and forearm, can spread to palm, and forearm
Diagnosis is made on four classic findingsDiagnosis is made on four classic findings..
1. tenderness over flexor tendon sheath1. tenderness over flexor tendon sheath
2. symmetric swelling of the finger (sausage 2. symmetric swelling of the finger (sausage
finger)finger)
3. pain with passive extension3. pain with passive extension
4. flexed posture of the involved digit at rest4. flexed posture of the involved digit at rest
Trigger fingerTrigger finger
Trigger finger is a painful condition caused by a narrowing of the sheath Trigger finger is a painful condition caused by a narrowing of the sheath
that surrounds the finger tendon. that surrounds the finger tendon.
Inflammation due to overuse is usually the cause.Inflammation due to overuse is usually the cause.
Tendons slide through a snug tunnelTendons slide through a snug tunnel. .
Irritation as the tendons slip into the tunnel can cause the opening of the 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 tunnel to become smaller, or the tendon to thicken so that it can't easily
pass through the tunnel. pass through the tunnel.
As you try to straighten the finger, the tendon becomes momentarily 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 stuck at the mouth of the tunnel then pops as the tendon slips past the
tight area. tight area.
No X-rays or other testing are usually needed No X-rays or other testing are usually needed
Tx:Tx:
NSAID’s, splint, cortisol injection, surgical releaseNSAID’s, splint, cortisol injection, surgical release
Trigger finger is a painful condition caused by a narrowing of the sheath Trigger finger is a painful condition caused by a narrowing of the sheath
that surrounds the finger tendon. that surrounds the finger tendon.
Inflammation due to overuse is usually the cause.Inflammation due to overuse is usually the cause.
Tendons slide through a snug tunnelTendons slide through a snug tunnel. .
Irritation as the tendons slip into the tunnel can cause the opening of the 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 tunnel to become smaller, or the tendon to thicken so that it can't easily
pass through the tunnel. pass through the tunnel.
As you try to straighten the finger, the tendon becomes momentarily 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 stuck at the mouth of the tunnel then pops as the tendon slips past the
tight area. tight area.
No X-rays or other testing are usually needed No X-rays or other testing are usually needed
Tx:Tx:
NSAID’s, splint, cortisol injection, surgical releaseNSAID’s, splint, cortisol injection, surgical release
Game Keeper’s ThumbGame Keeper’s Thumb
Skier’s ThumbSkier’s Thumb
Injury to the Injury to the ulnar collateral ligament of the MCP joint of the thumbulnar collateral ligament of the MCP joint of the thumb
Destroys joint stabilityDestroys joint stability
Impairs ability to pinchImpairs ability to pinch
Evaluation:Evaluation:
Stress ulnar aspect of the MCP joint by forcing thumb into radial Stress ulnar aspect of the MCP joint by forcing thumb into radial
abduction abduction
If there is <15 degrees of side to side difference (one thumb compared to the 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 other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical
repair is requiredrepair is required
Closed tx with a thumb spica cast or splint with the thumb slightly adducted may Closed tx with a thumb spica cast or splint with the thumb slightly adducted may
allow for healing of an incomplete tearallow for healing of an incomplete tear
Skier’s ThumbSkier’s Thumb
Injury to the Injury to the ulnar collateral ligament of the MCP joint of the thumbulnar collateral ligament of the MCP joint of the thumb
Destroys joint stabilityDestroys joint stability
Impairs ability to pinchImpairs ability to pinch
Evaluation:Evaluation:
Stress ulnar aspect of the MCP joint by forcing thumb into radial Stress ulnar aspect of the MCP joint by forcing thumb into radial
abduction abduction
If there is <15 degrees of side to side difference (one thumb compared to the 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 other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical
repair is requiredrepair is required
Closed tx with a thumb spica cast or splint with the thumb slightly adducted may Closed tx with a thumb spica cast or splint with the thumb slightly adducted may
allow for healing of an incomplete tearallow for healing of an incomplete tear
Game Keeper’s ThumbGame Keeper’s Thumb
(occupation, over period(occupation, over period
of time)of time)
Skier’s ThumbSkier’s Thumb
(sport, acutely) (sport, acutely)
(occupation, over period(occupation, over period
of time)of time)
Skier’s ThumbSkier’s Thumb
(sport, acutely) (sport, acutely)
De Quervain’s TenosynovitisDe Quervain’s Tenosynovitis
The disease is an entrapment tendonitis of the tendons The disease is an entrapment tendonitis of the tendons
contained within the first dorsal compartment at the wrist, contained within the first dorsal compartment at the wrist,
resulting in pain with thumb motion.resulting in pain with thumb motion.
The most classic finding in de Quervain tenosynovitis is a The most classic finding in de Quervain tenosynovitis is a
positive positive Finkelstein testFinkelstein test. .
Perform the Finkelstein test by having the patient make a fist with Perform the Finkelstein test by having the patient make a fist with
the thumb inside the fingers. the thumb inside the fingers.
The clinician then applies passive ulnar deviation of the wrist to The clinician then applies passive ulnar deviation of the wrist to
reproduce the chief complaint of dorsolateral wrist pain.reproduce the chief complaint of dorsolateral wrist pain.
Tx:Tx:
Splinting of the thumb and wrist relieves symptoms (although Splinting of the thumb and wrist relieves symptoms (although
noncompliance rates are high)noncompliance rates are high)
NSAIDSNSAIDS
Corticosteroid injectionCorticosteroid injection
Surgical releaseSurgical release
The disease is an entrapment tendonitis of the tendons The disease is an entrapment tendonitis of the tendons
contained within the first dorsal compartment at the wrist, contained within the first dorsal compartment at the wrist,
resulting in pain with thumb motion.resulting in pain with thumb motion.
The most classic finding in de Quervain tenosynovitis is a The most classic finding in de Quervain tenosynovitis is a
positive positive Finkelstein testFinkelstein test. .
Perform the Finkelstein test by having the patient make a fist with Perform the Finkelstein test by having the patient make a fist with
the thumb inside the fingers. the thumb inside the fingers.
The clinician then applies passive ulnar deviation of the wrist to The clinician then applies passive ulnar deviation of the wrist to
reproduce the chief complaint of dorsolateral wrist pain.reproduce the chief complaint of dorsolateral wrist pain.
Tx:Tx:
Splinting of the thumb and wrist relieves symptoms (although Splinting of the thumb and wrist relieves symptoms (although
noncompliance rates are high)noncompliance rates are high)
NSAIDSNSAIDS
Corticosteroid injectionCorticosteroid injection
Surgical releaseSurgical release
PositivePositive
Finkelstein testFinkelstein test..
Finkelstein testFinkelstein test..
ParonychiaParonychia
A paronychia is a superficial infection of epithelium A paronychia is a superficial infection of epithelium
lateral to the nail platelateral to the nail plate. .
The acute painful purulent infection is most frequently The acute painful purulent infection is most frequently
caused by staphylococci. caused by staphylococci.
The patient's condition and discomfort are markedly The patient's condition and discomfort are markedly
improved by a simple drainage procedure improved by a simple drainage procedure
A paronychia is a superficial infection of epithelium A paronychia is a superficial infection of epithelium
lateral to the nail platelateral to the nail plate. .
The acute painful purulent infection is most frequently The acute painful purulent infection is most frequently
caused by staphylococci. caused by staphylococci.
The patient's condition and discomfort are markedly The patient's condition and discomfort are markedly
improved by a simple drainage procedure improved by a simple drainage procedure
FelonFelon
Felons are closed-space infections of the Felons are closed-space infections of the fingertip pulpfingertip pulp. .
Fingertip pulp is divided into numerous small compartments Fingertip pulp is divided into numerous small compartments
by vertical septa that stabilize the pad. by vertical septa that stabilize the pad.
Infection occurring within these compartments can lead to Infection occurring within these compartments can lead to
abscess formation, edema, and rapid development of abscess formation, edema, and rapid development of
increased pressure in a closed space. increased pressure in a closed space.
This increased pressure may compromise blood flow and lead This increased pressure may compromise blood flow and lead
to necrosis of the skin and pulp.to necrosis of the skin and pulp.
Felons are closed-space infections of the Felons are closed-space infections of the fingertip pulpfingertip pulp. .
Fingertip pulp is divided into numerous small compartments Fingertip pulp is divided into numerous small compartments
by vertical septa that stabilize the pad. by vertical septa that stabilize the pad.
Infection occurring within these compartments can lead to Infection occurring within these compartments can lead to
abscess formation, edema, and rapid development of abscess formation, edema, and rapid development of
increased pressure in a closed space. increased pressure in a closed space.
This increased pressure may compromise blood flow and lead This increased pressure may compromise blood flow and lead
to necrosis of the skin and pulp.to necrosis of the skin and pulp.
Herpetic WhitlowHerpetic Whitlow
Herpes simplex virus may cause an intense, painful skin Herpes simplex virus may cause an intense, painful skin
infection. infection.
The fingertip is sore and swollen but is not as firm as in a The fingertip is sore and swollen but is not as firm as in a
felon. felon.
The appearance of The appearance of tiny fluid-filled blebs (vesicles) on the tiny fluid-filled blebs (vesicles) on the
fingers is diagnosticfingers is diagnostic. .
A herpetic whitlow is often mistaken for a felon. A herpetic whitlow is often mistaken for a felon.
The disorder eventually goes away on its own. The disorder eventually goes away on its own.
Surgery is not needed.Surgery is not needed.
Herpes simplex virus may cause an intense, painful skin Herpes simplex virus may cause an intense, painful skin
infection. infection.
The fingertip is sore and swollen but is not as firm as in a The fingertip is sore and swollen but is not as firm as in a
felon. felon.
The appearance of The appearance of tiny fluid-filled blebs (vesicles) on the tiny fluid-filled blebs (vesicles) on the
fingers is diagnosticfingers is diagnostic. .
A herpetic whitlow is often mistaken for a felon. A herpetic whitlow is often mistaken for a felon.
The disorder eventually goes away on its own. The disorder eventually goes away on its own.
Surgery is not needed.Surgery is not needed.
INFECTIONS CAUSED BY INFECTIONS CAUSED BY BITESBITES
The most common cause is injury to the knuckles by the teeth The most common cause is injury to the knuckles by the teeth
from a punch to the mouth. from a punch to the mouth.
Animal bites are also common causes. Animal bites are also common causes.
Wound contamination by a number of types of bacteria can result Wound contamination by a number of types of bacteria can result
from human and animal bites. from human and animal bites.
All bite injuries are potentially dangerous and can cause All bite injuries are potentially dangerous and can cause
significant infection. significant infection.
The injured area should be cleaned surgically, with the wound left The injured area should be cleaned surgically, with the wound left
open. open.
Antibiotics should be given to prevent joint infection (septic Antibiotics should be given to prevent joint infection (septic
arthritis), which can otherwise lead to permanent destruction of arthritis), which can otherwise lead to permanent destruction of
the knuckle joints. the knuckle joints.
Bacteria in human and animal bites are resistant to many Bacteria in human and animal bites are resistant to many
antibiotics but are generally sensitive to antibiotics but are generally sensitive to
ampicillin and penicillin. and penicillin.
(in practice use: augmentin)(in practice use: augmentin)
The most common cause is injury to the knuckles by the teeth The most common cause is injury to the knuckles by the teeth
from a punch to the mouth. from a punch to the mouth.
Animal bites are also common causes. Animal bites are also common causes.
Wound contamination by a number of types of bacteria can result Wound contamination by a number of types of bacteria can result
from human and animal bites. from human and animal bites.
All bite injuries are potentially dangerous and can cause All bite injuries are potentially dangerous and can cause
significant infection. significant infection.
The injured area should be cleaned surgically, with the wound left The injured area should be cleaned surgically, with the wound left
open. open.
Antibiotics should be given to prevent joint infection (septic Antibiotics should be given to prevent joint infection (septic
arthritis), which can otherwise lead to permanent destruction of arthritis), which can otherwise lead to permanent destruction of
the knuckle joints. the knuckle joints.
Bacteria in human and animal bites are resistant to many Bacteria in human and animal bites are resistant to many
antibiotics but are generally sensitive to antibiotics but are generally sensitive to
ampicillin and penicillin. and penicillin.
(in practice use: augmentin)(in practice use: augmentin)
The HandThe Hand
Nerves:Nerves:
RadialRadial::
Provides sensation to dorsum of hand on radial side of third metacarpal & Provides sensation to dorsum of hand on radial side of third metacarpal &
dorsal thmb, index, & middle fingers as far as the distal phalanges.dorsal thmb, index, & middle fingers as far as the distal phalanges.
The first web space is the most ‘pure’ area to test radial nerve sensation.The first web space is the most ‘pure’ area to test radial nerve sensation.
Motor= test thumb extension- hitchikingMotor= test thumb extension- hitchiking
UlnarUlnar::
Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little
fingers.fingers.
The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve
sensationsensation
Motor= test opposition (little finger), finger adductionMotor= test opposition (little finger), finger adduction
MedianMedian::
Provides sensation to palm & palmar surface of thumb, index, middle, & half Provides sensation to palm & palmar surface of thumb, index, middle, & half
of ring finger; may supply dorsum of terminal phalanges of these fingersof ring finger; may supply dorsum of terminal phalanges of these fingers
The distal palmer aspect of the index finger is the most ‘pure’ area to test The distal palmer aspect of the index finger is the most ‘pure’ area to test
median nerve sensationmedian nerve sensation
Motor= test opposition (thumb)Motor= test opposition (thumb)
Nerves:Nerves:
RadialRadial::
Provides sensation to dorsum of hand on radial side of third metacarpal & Provides sensation to dorsum of hand on radial side of third metacarpal &
dorsal thmb, index, & middle fingers as far as the distal phalanges.dorsal thmb, index, & middle fingers as far as the distal phalanges.
The first web space is the most ‘pure’ area to test radial nerve sensation.The first web space is the most ‘pure’ area to test radial nerve sensation.
Motor= test thumb extension- hitchikingMotor= test thumb extension- hitchiking
UlnarUlnar::
Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little
fingers.fingers.
The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve
sensationsensation
Motor= test opposition (little finger), finger adductionMotor= test opposition (little finger), finger adduction
MedianMedian::
Provides sensation to palm & palmar surface of thumb, index, middle, & half Provides sensation to palm & palmar surface of thumb, index, middle, & half
of ring finger; may supply dorsum of terminal phalanges of these fingersof ring finger; may supply dorsum of terminal phalanges of these fingers
The distal palmer aspect of the index finger is the most ‘pure’ area to test The distal palmer aspect of the index finger is the most ‘pure’ area to test
median nerve sensationmedian nerve sensation
Motor= test opposition (thumb)Motor= test opposition (thumb)
UE Arteries & NervesUE Arteries & Nerves
Crutch misuseCrutch misuse
Thoracic Outlet ObstructionThoracic Outlet Obstruction
Carpal TunnelCarpal Tunnel
Cubital TunnelCubital Tunnel
Saturday Night PalsySaturday Night Palsy
Crutch misuseCrutch misuse
Thoracic Outlet ObstructionThoracic Outlet Obstruction
Carpal TunnelCarpal Tunnel
Cubital TunnelCubital Tunnel
Saturday Night PalsySaturday Night Palsy
Thoracic Outlet SyndromeThoracic Outlet Syndrome
Usually resulting Usually resulting from irritation of C8 and T1 from irritation of C8 and T1
innervated nerves, innervated nerves,
may be caused by may be caused by
a cervical rib, a cervical rib,
a fiber spanning from a rudimentary cervical rib, a fiber spanning from a rudimentary cervical rib,
tendinous bands from the scalenus anterior to the medius tendinous bands from the scalenus anterior to the medius
muscles or muscles or
hypertrophic clavicle fracture callushypertrophic clavicle fracture callus
Neurologic, venous, or arterial symptomsNeurologic, venous, or arterial symptoms
Tx:Tx:
Postural exercisesPostural exercises
Surgical resection of cervical rib, first rib, or scalenotomySurgical resection of cervical rib, first rib, or scalenotomy
Usually resulting Usually resulting from irritation of C8 and T1 from irritation of C8 and T1
innervated nerves, innervated nerves,
may be caused by may be caused by
a cervical rib, a cervical rib,
a fiber spanning from a rudimentary cervical rib, a fiber spanning from a rudimentary cervical rib,
tendinous bands from the scalenus anterior to the medius tendinous bands from the scalenus anterior to the medius
muscles or muscles or
hypertrophic clavicle fracture callushypertrophic clavicle fracture callus
Neurologic, venous, or arterial symptomsNeurologic, venous, or arterial symptoms
Tx:Tx:
Postural exercisesPostural exercises
Surgical resection of cervical rib, first rib, or scalenotomySurgical resection of cervical rib, first rib, or scalenotomy
Carpal TunnelCarpal Tunnel
The syndrome is characterized by pain, paresthesias, and The syndrome is characterized by pain, paresthesias, and
weakness in weakness in the the median nervemedian nerve distribution of the hand. distribution of the hand.
Trauma vs. repetitive motionTrauma vs. repetitive motion
Acute CTS can be thought of as a compartment syndrome of Acute CTS can be thought of as a compartment syndrome of
the carpal canal, and decompression should be performed as the carpal canal, and decompression should be performed as
soon as possible soon as possible
Tinel’s and Phalen’s testsTinel’s and Phalen’s tests, nerve conduction studies, nerve conduction studies
Tx:Tx:
Steroid inj, splinting, NSAID’s, surgical releaseSteroid inj, splinting, NSAID’s, surgical release
The syndrome is characterized by pain, paresthesias, and The syndrome is characterized by pain, paresthesias, and
weakness in weakness in the the median nervemedian nerve distribution of the hand. distribution of the hand.
Trauma vs. repetitive motionTrauma vs. repetitive motion
Acute CTS can be thought of as a compartment syndrome of Acute CTS can be thought of as a compartment syndrome of
the carpal canal, and decompression should be performed as the carpal canal, and decompression should be performed as
soon as possible soon as possible
Tinel’s and Phalen’s testsTinel’s and Phalen’s tests, nerve conduction studies, nerve conduction studies
Tx:Tx:
Steroid inj, splinting, NSAID’s, surgical releaseSteroid inj, splinting, NSAID’s, surgical release
Cubital Tunnel SyndromeCubital Tunnel Syndrome
is the effect of pressure on the is the effect of pressure on the “funny bone” “funny bone”
causing pain, paresthesia’s to the causing pain, paresthesia’s to the ulnar nerve ulnar nerve
distributiondistribution
is the effect of pressure on the is the effect of pressure on the “funny bone” “funny bone”
causing pain, paresthesia’s to the causing pain, paresthesia’s to the ulnar nerve ulnar nerve
distributiondistribution
Saturday Night Palsy Saturday Night Palsy
The patient has injured his upper arm, usually by sleeping with The patient has injured his upper arm, usually by sleeping with
his arm over the back of a chair, and now presents holding the his arm over the back of a chair, and now presents holding the
affected hand and wrist with his good hand, complaining of affected hand and wrist with his good hand, complaining of
decreased or absent sensation on the radial and dorsal side of decreased or absent sensation on the radial and dorsal side of
his hand and wrist, and of inability to extend his wrist, thumb his hand and wrist, and of inability to extend his wrist, thumb
and finger joints. and finger joints.
With the hand supinated (palm up) and the extensors aided by With the hand supinated (palm up) and the extensors aided by
gravity, hand function may appear normal, but when the hand gravity, hand function may appear normal, but when the hand
is pronated (palm down) the wrist is pronated (palm down) the wrist and hand will drop.and hand will drop.
The patient has injured his upper arm, usually by sleeping with The patient has injured his upper arm, usually by sleeping with
his arm over the back of a chair, and now presents holding the his arm over the back of a chair, and now presents holding the
affected hand and wrist with his good hand, complaining of affected hand and wrist with his good hand, complaining of
decreased or absent sensation on the radial and dorsal side of decreased or absent sensation on the radial and dorsal side of
his hand and wrist, and of inability to extend his wrist, thumb his hand and wrist, and of inability to extend his wrist, thumb
and finger joints. and finger joints.
With the hand supinated (palm up) and the extensors aided by With the hand supinated (palm up) and the extensors aided by
gravity, hand function may appear normal, but when the hand gravity, hand function may appear normal, but when the hand
is pronated (palm down) the wrist is pronated (palm down) the wrist and hand will drop.and hand will drop.
Enlargement of the Lymph Enlargement of the Lymph
Nodes (Lymphadenopathy)Nodes (Lymphadenopathy)
Infection (streaking)Infection (streaking)
Lymphangitis:Lymphangitis: inflammation of the lymph inflammation of the lymph
vessels.vessels.
Breast Ca (sentinel node)Breast Ca (sentinel node)
LymphedemaLymphedema
Nodes (Lymphadenopathy)Nodes (Lymphadenopathy)
Infection (streaking)Infection (streaking)
Lymphangitis:Lymphangitis: inflammation of the lymph inflammation of the lymph
vessels.vessels.
Breast Ca (sentinel node)Breast Ca (sentinel node)
LymphedemaLymphedema
'Excellence is an art won by training and habituation. We do not act rightly because'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 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.'We are what we repeatedly do. Excellence, then, is not an act but a habit.'
AristotelesAristoteles
A journey of a thousand miles begins with a single step.
Lao Tsu
“I find that the harder I work, the more luck I seem to have”.
Thomas Jefferson
Self conquest is the greatest of victories.Self conquest is the greatest of victories.
PlatoPlato
““Imagination is everything. It is the preview of life’s comingImagination is everything. It is the preview of life’s coming
attractions.”attractions.”
Albert EinsteinAlbert Einstein
Nothing great was ever achieved without enthusiasm.
Ralph Waldo Emerson
““If a man empties his purse into his head, no man can take it If a man empties his purse into his head, no man can take it
away from him. An investment in knowledge always pays the bestaway from him. An investment in knowledge always pays the best
interest” Benjamin Franklininterest” Benjamin Franklin
we have virtue or excellence, but rather we have those because we have acted rightly. 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.'We are what we repeatedly do. Excellence, then, is not an act but a habit.'
AristotelesAristoteles
A journey of a thousand miles begins with a single step.
Lao Tsu
“I find that the harder I work, the more luck I seem to have”.
Thomas Jefferson
Self conquest is the greatest of victories.Self conquest is the greatest of victories.
PlatoPlato
““Imagination is everything. It is the preview of life’s comingImagination is everything. It is the preview of life’s coming
attractions.”attractions.”
Albert EinsteinAlbert Einstein
Nothing great was ever achieved without enthusiasm.
Ralph Waldo Emerson
““If a man empties his purse into his head, no man can take it If a man empties his purse into his head, no man can take it
away from him. An investment in knowledge always pays the bestaway from him. An investment in knowledge always pays the best
interest” Benjamin Franklininterest” Benjamin Franklin
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